Provider Demographics
NPI:1750329504
Name:CAMPBELL, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3379 CHILI AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-5325
Mailing Address - Country:US
Mailing Address - Phone:585-889-0750
Mailing Address - Fax:585-889-0759
Practice Address - Street 1:3379 CHILI AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5325
Practice Address - Country:US
Practice Address - Phone:585-889-0750
Practice Address - Fax:585-889-0759
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239294208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02775588Medicaid
NYJ400046994/GP BA0017Medicare PIN
NY02775588Medicaid