Basic Information
| Provider Information | |||||||||
| NPI: | 1073646253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S. 48TH | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 E GREENWOOD | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707779800 | ||||||||
| FaxNumber: | 8707779811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.