Provider Demographics
NPI:1366192098
Name:CAMPBELL, JENNIFER WILEY (LMSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WILEY
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 FRESH POND RD APT 5
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5233
Mailing Address - Country:US
Mailing Address - Phone:713-248-0753
Mailing Address - Fax:
Practice Address - Street 1:6801 FRESH POND RD APT 5
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5233
Practice Address - Country:US
Practice Address - Phone:713-248-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111415104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker