Provider Demographics
NPI:1245506815
Name:CAMPBELL, JACQUELYN DORN (MS,LD)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:DORN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E JONES ST
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-1943
Mailing Address - Country:US
Mailing Address - Phone:830-875-5507
Mailing Address - Fax:
Practice Address - Street 1:522 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-2613
Practice Address - Country:US
Practice Address - Phone:830-351-0566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT01962133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education