Provider Demographics
NPI:1053742544
Name:CAMPBELL, JEREMY TODD
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2727
Mailing Address - Country:US
Mailing Address - Phone:732-887-2540
Mailing Address - Fax:610-419-3309
Practice Address - Street 1:826 DELEWARE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:610-419-3101
Practice Address - Fax:610-419-3309
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral