Provider Demographics
NPI:1922879030
Name:CAMPBELL, JONATHAN RANDOLPH (LPC CANDIDATE)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RANDOLPH
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N PHILADELPHIA AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7032
Mailing Address - Country:US
Mailing Address - Phone:405-585-3195
Mailing Address - Fax:
Practice Address - Street 1:1016 SW 44TH ST STE 500
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3615
Practice Address - Country:US
Practice Address - Phone:405-605-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11928101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health