MEDICARE: DR. JENNINER CAMPION PH.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	103TC0700X	Clinical Psychologist	4689	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	800387	OTHER	MA	TUFTS
2	W04560	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1508939547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNINER CAMPION PH.D.

Provider Business Mailing Address
First Line	:	17 AVERY SQ STE G
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02494-1359
Country	:	US
Telephone Number	:	781-449-8870
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 AVERY SQ STE G
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02494-1359
Country	:	US
Telephone Number	:	781-449-8870
Fax Number	:

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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