Healthcare Provider Details

I. General information

NPI: 1902610959
Provider Name (Legal Business Name): JONATHAN M CAMPBELL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2025
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MARSH LILY DR
SYLVA NC
28779-9477
US

IV. Provider business mailing address

261 LOG CABIN LN
CULLOWHEE NC
28723-6728
US

V. Phone/Fax

Practice location:
  • Phone: 828-631-1422
  • Fax:
Mailing address:
  • Phone: 706-612-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number5572
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5572
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: