Healthcare Provider Details

I. General information

NPI: 1578194445
Provider Name (Legal Business Name): JAKAYLA CAMPBELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3096 SPRING HILL PKWY SE APT F
SMYRNA GA
30080-4752
US

IV. Provider business mailing address

3096 SPRING HILL PKWY SE APT F
SMYRNA GA
30080-4752
US

V. Phone/Fax

Practice location:
  • Phone: 843-532-1531
  • Fax:
Mailing address:
  • Phone: 843-532-1531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT003670
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: