Provider Demographics
NPI:1912299025
Name:CAMPOSANO-WALLACE, JENNIFER (LMHC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:CAMPOSANO-WALLACE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 N FEDERAL HWY STE 120
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-1679
Mailing Address - Country:US
Mailing Address - Phone:561-598-9115
Mailing Address - Fax:
Practice Address - Street 1:7940 N FEDERAL HWY STE 120
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1679
Practice Address - Country:US
Practice Address - Phone:561-598-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-07
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health