Provider Demographics
NPI:1598970915
Name:CAMPBELL, JESSICA LEIGH (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEIGH
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2564
Mailing Address - Country:US
Mailing Address - Phone:509-758-5070
Mailing Address - Fax:
Practice Address - Street 1:821 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2002
Practice Address - Country:US
Practice Address - Phone:509-758-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0171574OtherL&I
WA56-2333756OtherEIN