Healthcare Provider Details

I. General information

NPI: 1225789464
Provider Name (Legal Business Name): JORDAN CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3527 FAIRMONT AVE
FAIRMONT WV
26554-3474
US

IV. Provider business mailing address

3527 FAIRMONT AVE
FAIRMONT WV
26554-3474
US

V. Phone/Fax

Practice location:
  • Phone: 681-489-6221
  • Fax:
Mailing address:
  • Phone: 681-489-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2588
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: