Provider Demographics
NPI:1659469336
Name:CAMPBELL, JOHN JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42D MEDICAL GROUP
Mailing Address - Street 2:300 TWINING STREET
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:334-953-5143
Mailing Address - Fax:334-953-8296
Practice Address - Street 1:42D MEDICAL GROUP
Practice Address - Street 2:300 TWINING STREET
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-5143
Practice Address - Fax:334-953-8296
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS665103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist