=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164863940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANA CAMPISI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2013
-----------------------------------------------------
Last Update Date | 07/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 DEERFIELD PL
-----------------------------------------------------
City | FLANDERS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07836-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-670-2624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 DEERFIELD PL
-----------------------------------------------------
City | FLANDERS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07836-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-670-2624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05195200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------