Provider Demographics
NPI:1295254936
Name:CAMPOS, JONATHAN MARC
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARC
Last Name:CAMPOS
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 1:9603 SKY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-5810
Mailing Address - Country:US
Mailing Address - Phone:808-227-4401
Mailing Address - Fax:
Practice Address - Street 1:5803 W CRAIG RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2537
Practice Address - Country:US
Practice Address - Phone:702-901-5200
Practice Address - Fax:702-901-5201
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health