Healthcare Provider Details

I. General information

NPI: 1841043320
Provider Name (Legal Business Name): JORGE CAMPOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E ENOS DR STE A
SANTA MARIA CA
93454-7215
US

IV. Provider business mailing address

3858 N TILDEN ST
VISALIA CA
93291-9386
US

V. Phone/Fax

Practice location:
  • Phone: 805-614-9160
  • Fax:
Mailing address:
  • Phone: 559-713-8553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number162889
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: