Provider Demographics
NPI:1821719873
Name:CAMPBELL, JACOB WADE
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WADE
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 1:8808 HIGHWAY 81 S
Mailing Address - Street 2:
Mailing Address - City:STARR
Mailing Address - State:SC
Mailing Address - Zip Code:29684-9413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 TANDEM DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4726
Practice Address - Country:US
Practice Address - Phone:864-655-7757
Practice Address - Fax:864-655-7747
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11522OtherPT LICENSE