Healthcare Provider Details

I. General information

NPI: 1720339559
Provider Name (Legal Business Name): JACQUELINE K CAMPBELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8988 LORTON MARKET STREET # 100
LORTON VA
22079
US

IV. Provider business mailing address

8988 LORTON MARKET STREET SUITE 100
LORTON VA
22079
US

V. Phone/Fax

Practice location:
  • Phone: 703-780-2800
  • Fax: 703-780-0461
Mailing address:
  • Phone: 703-780-2800
  • Fax: 703-780-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024170267
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: