Provider Demographics
NPI:1790371078
Name:CAMPBELL, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-1302
Mailing Address - Country:US
Mailing Address - Phone:757-288-3093
Mailing Address - Fax:
Practice Address - Street 1:223 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-1302
Practice Address - Country:US
Practice Address - Phone:757-288-3093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401135473376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty