Provider Demographics
NPI:1740490655
Name:CAMPBELL, JASON LAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LAYNE
Last Name:CAMPBELL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9600, DEPT 09-038
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-9600
Mailing Address - Country:US
Mailing Address - Phone:877-243-8416
Mailing Address - Fax:
Practice Address - Street 1:1505 E BERT KOUNS INDUSTRIAL LOOP STE 201
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5723
Practice Address - Country:US
Practice Address - Phone:318-681-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010800562085R0202X
MO20070131522085R0202X
LA2020982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365807Medicaid