Provider Demographics
NPI:1912537010
Name:CAMPBELL, JILLIAN L
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:L
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 1:340 DOGWOOD AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-3400
Mailing Address - Country:US
Mailing Address - Phone:516-505-1717
Mailing Address - Fax:516-505-1627
Practice Address - Street 1:340 DOGWOOD AVE STE 106
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-3400
Practice Address - Country:US
Practice Address - Phone:516-505-1717
Practice Address - Fax:516-505-1627
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011774101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health