Basic Information
| Provider Information | |||||||||
| NPI: | 1194906784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CAROLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | BAY VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441402550 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14519 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441074316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165214200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2007 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 090769 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2805352 | 05 | OH | MEDICAID |