=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689403719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALESHA K CAMPBELL MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2024
-----------------------------------------------------
Last Update Date | 07/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N19W24101 RIVERWOOD DR
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53188-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-444-0601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2645 N 52ND ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53210-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-699-9679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 7564-226
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------