Healthcare Provider Details

I. General information

NPI: 1518553403
Provider Name (Legal Business Name): JACKIE R CAMP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUEILINE R CRAWFORD NP

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 NW 10TH ST
FAIRFIELD IL
62837-1216
US

IV. Provider business mailing address

213 NW 10TH ST
FAIRFIELD IL
62837-1216
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4617
  • Fax: 618-380-4565
Mailing address:
  • Phone: 618-842-4617
  • Fax: 618-380-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28156286A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: