Healthcare Provider Details

I. General information

NPI: 1578266698
Provider Name (Legal Business Name): JENNIFER L. CAMPBELL MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 ALWICK AVE
WEST ISLIP NY
11795-4001
US

IV. Provider business mailing address

107 WOODLAND DR
EAST ISLIP NY
11730-3211
US

V. Phone/Fax

Practice location:
  • Phone: 631-533-2651
  • Fax:
Mailing address:
  • Phone: 631-581-6680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: