Healthcare Provider Details

I. General information

NPI: 1215283536
Provider Name (Legal Business Name): ELIZABETH CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10503 SAN JOSE BLVD
JACKSONVILLE FL
32257
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-6700
  • Fax: 904-450-6691
Mailing address:
  • Phone: 904-296-5691
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW10835
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: