Provider Demographics
NPI:1124881453
Name:CAMPO, JENNIFER LISBETH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LISBETH
Last Name:CAMPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5204
Mailing Address - Country:US
Mailing Address - Phone:786-790-7305
Mailing Address - Fax:
Practice Address - Street 1:3430 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5204
Practice Address - Country:US
Practice Address - Phone:786-790-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-309576106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician