=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770090243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASPER AHMAD CAMPBELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2018
-----------------------------------------------------
Last Update Date | 04/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 E CENTER ST STE 200J
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-5348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-301-8427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 CARLTON ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-231-6845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | AR5510
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------