Provider Demographics
NPI:1609812882
Name:CAMPBELL, JENNIFER A (PSY D)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 EASTWOOD DR STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5387
Mailing Address - Country:US
Mailing Address - Phone:608-255-9119
Mailing Address - Fax:608-255-9219
Practice Address - Street 1:2010 EASTWOOD DR STE 202
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5387
Practice Address - Country:US
Practice Address - Phone:608-255-9119
Practice Address - Fax:608-255-9219
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2194057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39778700Medicaid