Provider Demographics
NPI:1518023563
Name:CAMPBELL, JEAN AMOS (LMFT)
Entity type:Individual
Prefix:MS
First Name:JEAN
Middle Name:AMOS
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2192
Mailing Address - Country:US
Mailing Address - Phone:502-493-0343
Mailing Address - Fax:502-493-0343
Practice Address - Street 1:3044 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 204
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2192
Practice Address - Country:US
Practice Address - Phone:502-493-0343
Practice Address - Fax:502-493-0343
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0012106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY099696OtherVALUEOPTIONS PROVIDER #