Healthcare Provider Details

I. General information

NPI: 1750741336
Provider Name (Legal Business Name): JACKELYNN CAMPOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COOLIDGE AVE
OAKLAND CA
94602-3399
US

IV. Provider business mailing address

3800 COOLIDGE AVE
OAKLAND CA
94602-3399
US

V. Phone/Fax

Practice location:
  • Phone: 510-482-2244
  • Fax: 510-488-1960
Mailing address:
  • Phone: 510-482-2244
  • Fax: 510-488-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95210993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: