MEDICARE: JADA BLAIZ CAMPBELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1063167278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADA BLAIZ CAMPBELL

Provider Business Mailing Address
First Line	:	6800 PARK TEN BLVD STE 125N
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-4291
Country	:	US
Telephone Number	:	210-685-2266
Fax Number	:	210-468-5573

Provider Business Practice Location Address
First Line	:	6800 PARK TEN BLVD STE 125N
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-4291
Country	:	US
Telephone Number	:	210-685-2266
Fax Number	:	210-468-5573

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2022
Last Update Date	:	02/16/2022

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Directions to “ JADA BLAIZ CAMPBELL ” Practice Location

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