Basic Information
Provider Information | |||||||||
NPI: | 1992807218 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | EVA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOODWARD | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | EVA | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RDH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 411 NW 10TH ST | ||||||||
Address2: |   | ||||||||
City: | PENDLETON | ||||||||
State: | OR | ||||||||
PostalCode: | 978011357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412762009 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 73265 CONFEDERATED WAY | ||||||||
Address2: |   | ||||||||
City: | PENDLETON | ||||||||
State: | OR | ||||||||
PostalCode: | 97801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419669830 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 03/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H4174 | OR | Y |   | Dental Providers | Dental Hygienist |   |
ID Information
ID | Type | State | Issuer | Description | 171037 | 05 | OR |   | MEDICAID |