Healthcare Provider Details

I. General information

NPI: 1235528399
Provider Name (Legal Business Name): MS. JILL TERESA CAMPOLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 VITALIA ST
SANTA FE NM
87505-3278
US

IV. Provider business mailing address

1231 VITALIA ST
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 617-407-2460
  • Fax:
Mailing address:
  • Phone: 617-407-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0167051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: