Provider Demographics
NPI:1912245143
Name:CAMPBELL, JENNI MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNI
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N MAIN ST
Mailing Address - Street 2:PO BOX G
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1126
Mailing Address - Country:US
Mailing Address - Phone:802-728-4466
Mailing Address - Fax:
Practice Address - Street 1:11 N MAIN ST
Practice Address - Street 2:PO BOX G
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1126
Practice Address - Country:US
Practice Address - Phone:802-728-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.00841081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical