Provider Demographics
NPI:1497541809
Name:CAMPBELL, JACQUETTA DENISE (LCMHC-A)
Entity type:Individual
Prefix:
First Name:JACQUETTA
Middle Name:DENISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 DONNINGTON LN NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-3322
Mailing Address - Country:US
Mailing Address - Phone:704-754-7817
Mailing Address - Fax:
Practice Address - Street 1:2315 E WT HARRIS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5133
Practice Address - Country:US
Practice Address - Phone:704-208-4458
Practice Address - Fax:866-309-6385
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional