Provider Demographics
NPI:1780026930
Name:CAMPOS, JON (PPS CREDENTIAL)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:PPS CREDENTIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1444
Mailing Address - Country:US
Mailing Address - Phone:619-575-4687
Mailing Address - Fax:
Practice Address - Street 1:892 27TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1444
Practice Address - Country:US
Practice Address - Phone:619-575-4687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120548048101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool