Provider Demographics
NPI:1396564472
Name:CAMPBELL, ATHENA JADE
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:JADE
Last Name:CAMPBELL
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 1:4850 MARK CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1882
Mailing Address - Country:US
Mailing Address - Phone:703-746-3400
Mailing Address - Fax:
Practice Address - Street 1:4850 MARK CENTER DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1882
Practice Address - Country:US
Practice Address - Phone:703-746-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016223101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor