Healthcare Provider Details

I. General information

NPI: 1023232477
Provider Name (Legal Business Name): JENNIFER CAMPBELL CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 STATE STREET
LA PORTE IN
46350-3429
US

IV. Provider business mailing address

P.O. BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-3431
  • Fax: 219-362-3802
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71000545A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: