Provider Demographics
NPI:1578194445
Name:CAMPBELL, JAKAYLA (ATC)
Entity Type:Individual
Prefix:
First Name:JAKAYLA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3096 SPRING HILL PKWY SE APT F
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4752
Mailing Address - Country:US
Mailing Address - Phone:843-532-1531
Mailing Address - Fax:
Practice Address - Street 1:3096 SPRING HILL PKWY SE APT F
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4752
Practice Address - Country:US
Practice Address - Phone:843-532-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0036702081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10131993OtherBITHDAY