Provider Demographics
NPI:1578266698
Name:CAMPBELL, JENNIFER L (MHC-LP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3211
Mailing Address - Country:US
Mailing Address - Phone:631-581-6680
Mailing Address - Fax:
Practice Address - Street 1:621 ALWICK AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4001
Practice Address - Country:US
Practice Address - Phone:631-533-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty