MEDICARE: JESSICA RENA CAMPBELL PCC

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	101YP2500X	Professional Counselor	E0500044	OH

General Provider Information

NPI Number	:	1194851634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RENA CAMPBELL PCC

Provider Business Mailing Address
First Line	:	5838 HIGHVIEW DR
Second Line	:
City	:	MILFORD
State	:	OH
Zip	:	45150-2038
Country	:	US
Telephone Number	:	513-305-1437
Fax Number	:

Provider Business Practice Location Address
First Line	:	7843 LAUREL AVE
Second Line	:
City	:	MADEIRA
State	:	OH
Zip	:	45243-2608
Country	:	US
Telephone Number	:	513-561-5600
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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