Provider Demographics
NPI:1689214751
Name:CAMPBELL, ANDREW JERROD
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JERROD
Last Name:CAMPBELL
Suffix:
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 1:345A DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1420
Mailing Address - Country:US
Mailing Address - Phone:619-633-6166
Mailing Address - Fax:
Practice Address - Street 1:345A DELAWARE ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1420
Practice Address - Country:US
Practice Address - Phone:619-633-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)