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General NPI Number Information
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NPI Number | 1619368180
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Entity Type | Individual
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Provider Name | JACQUELINE CAMPBELL
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Gender | Female
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Dates
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Enumeration Date | 02/05/2015
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Last Update Date | 02/05/2015
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Provider Practice Location Address
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Address Line | 3189 SW FAMBROUGH ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-4541
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Country | US
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Telephone | 772-203-3026
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Fax |
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Provider Business Mailing Address
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Address Line | 3189 SW FAMBROUGH ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-4541
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Country | US
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Telephone | 772-203-3026
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | RN 9219448
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN 9219448
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | RN 9219448
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | RN 9219448
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License Number State | FL
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Taxonomy #5
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Taxonomy Code | 3747A0650X
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Taxonomy Name | Attendant Care Provider
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License Number | RN 9219448
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License Number State | FL
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