Provider Demographics
NPI:1063812162
Name:CAMPBELL, JEREMY BRIAN (PT, DPT, CSCS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BRIAN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 E ONTARIO ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3385
Mailing Address - Country:US
Mailing Address - Phone:312-527-9201
Mailing Address - Fax:312-527-9201
Practice Address - Street 1:227 E ONTARIO ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3385
Practice Address - Country:US
Practice Address - Phone:312-527-9201
Practice Address - Fax:312-527-9201
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist