Provider Demographics
NPI:1205690781
Name:CAMPBELL, JESSICA LYNN (CSFA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10589 FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-4321
Mailing Address - Country:US
Mailing Address - Phone:161-857-0037
Mailing Address - Fax:
Practice Address - Street 1:10589 FOXTAIL DR
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-4321
Practice Address - Country:US
Practice Address - Phone:618-570-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000728246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant