Provider Demographics
NPI:1912309634
Name:CAMPBELL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5756 FORDHAM CIR
Mailing Address - Street 2:PLEASE SELECT
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3344
Mailing Address - Country:US
Mailing Address - Phone:248-943-8009
Mailing Address - Fax:
Practice Address - Street 1:5756 FORDHAM CIR
Practice Address - Street 2:PLEASE SELECT
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3344
Practice Address - Country:US
Practice Address - Phone:248-943-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010970771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical