Provider Demographics
NPI:1649041971
Name:CAMPBELL, JEFFERY ROSS (PHD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROSS
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 ENCANTO RD
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-3500
Mailing Address - Country:US
Mailing Address - Phone:509-981-0349
Mailing Address - Fax:
Practice Address - Street 1:5360 ENCANTO RD
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-3500
Practice Address - Country:US
Practice Address - Phone:509-981-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61214206101YM0800X
AZLAC-08067T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health