Healthcare Provider Details

I. General information

NPI: 1598727448
Provider Name (Legal Business Name): JACQUELINE LEE CAMPOS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PURCHASE ST
NEW BEDFORD MA
02740-6355
US

IV. Provider business mailing address

800 PURCHASE ST
NEW BEDFORD MA
02740-6355
US

V. Phone/Fax

Practice location:
  • Phone: 508-992-1088
  • Fax: 508-992-1088
Mailing address:
  • Phone: 508-992-1088
  • Fax: 508-992-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5604
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: