Healthcare Provider Details

I. General information

NPI: 1235947227
Provider Name (Legal Business Name): JEREMY CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S LAS VEGAS TRL
WHITE SETTLEMENT TX
76108-3350
US

IV. Provider business mailing address

101 RHOADES ST
AZLE TX
76020-4422
US

V. Phone/Fax

Practice location:
  • Phone: 817-246-4995
  • Fax:
Mailing address:
  • Phone: 817-798-4901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2158422
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: