Provider Demographics
NPI:1912271594
Name:CAMPBELL, JESSICA TATE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TATE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:FAYE
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1008 COVEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-7555
Mailing Address - Country:US
Mailing Address - Phone:205-915-6331
Mailing Address - Fax:
Practice Address - Street 1:1008 COVEWOOD LN
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-7555
Practice Address - Country:US
Practice Address - Phone:205-915-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist