Provider Demographics
NPI:1730773011
Name:CAMPBELL, JERADINE
Entity type:Individual
Prefix:
First Name:JERADINE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-2146
Mailing Address - Country:US
Mailing Address - Phone:850-274-3360
Mailing Address - Fax:
Practice Address - Street 1:345 GREEN ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2146
Practice Address - Country:US
Practice Address - Phone:850-274-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA99144376K00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105244100Medicaid