Provider Demographics
NPI:1821395039
Name:CAMPBELL, JENNIFER L (MA, LLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:114 TUSCOLA RD.
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6995
Mailing Address - Country:US
Mailing Address - Phone:989-895-0788
Mailing Address - Fax:989-895-0799
Practice Address - Street 1:114 TUSCOLA
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6995
Practice Address - Country:US
Practice Address - Phone:989-895-0788
Practice Address - Fax:989-895-0799
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014102103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist