Provider Demographics
NPI:1790039162
Name:CAMPBELL, JENNA CHRISTEN (APN)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:CHRISTEN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2536
Mailing Address - Country:US
Mailing Address - Phone:870-773-4655
Mailing Address - Fax:
Practice Address - Street 1:1312 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2135
Practice Address - Country:US
Practice Address - Phone:870-584-7115
Practice Address - Fax:870-642-3388
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003780363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA003780OtherSTATE LICENSE