MEDICARE: JENNIFER PATRICIA CAMPBELL MA, LPC, CCDP-D

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	101Y00000X	Counselor	2008010475	MO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	5030	MO
3	101YP2500X	Professional Counselor	2008010475	MO

General Provider Information

NPI Number	:	1306178918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER PATRICIA CAMPBELL MA, LPC, CCDP-D

Provider Business Mailing Address
First Line	:	9433 THEODOSIA AVE
Second Line	:
City	:	OVERLAND
State	:	MO
Zip	:	63114-3715
Country	:	US
Telephone Number	:	314-566-2290
Fax Number	:

Provider Business Practice Location Address
First Line	:	939 GARDENVIEW OFFICE PKWY
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-5917
Country	:	US
Telephone Number	:	314-566-2290
Fax Number	:

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

Provider Enumeration Date	:	02/06/2010
Last Update Date	:	02/06/2010

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