Healthcare Provider Details

I. General information

NPI: 1073108817
Provider Name (Legal Business Name): JAZMINE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4739
US

IV. Provider business mailing address

12929 ROSEMONT ST
OCEAN SPRINGS MS
39564-9124
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-3607
  • Fax:
Mailing address:
  • Phone: 228-218-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number802658211
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number802658211
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: