Healthcare Provider Details

I. General information

NPI: 1063337095
Provider Name (Legal Business Name): JEAN MARIE CAMPBELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 BROADWAY ST STE 208
LAGUNA BEACH CA
92651-4311
US

IV. Provider business mailing address

17192 MURPHY AVE UNIT 14108
IRVINE CA
92623-0406
US

V. Phone/Fax

Practice location:
  • Phone: 310-909-9780
  • Fax:
Mailing address:
  • Phone: 310-909-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: