Provider Demographics
NPI:1770090243
Name:CAMPBELL, JASPER AHMAD
Entity type:Individual
Prefix:
First Name:JASPER
Middle Name:AHMAD
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5103
Mailing Address - Country:US
Mailing Address - Phone:479-231-6845
Mailing Address - Fax:
Practice Address - Street 1:31 E CENTER ST STE 200J
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5348
Practice Address - Country:US
Practice Address - Phone:479-301-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR5510253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care