Provider Demographics
NPI:1518553403
Name:CAMP, JACKIE R (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:CAMP
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:JACQUEILINE
Other - Middle Name:R
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:213 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1216
Mailing Address - Country:US
Mailing Address - Phone:618-842-4617
Mailing Address - Fax:618-380-4565
Practice Address - Street 1:213 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1216
Practice Address - Country:US
Practice Address - Phone:618-842-4617
Practice Address - Fax:618-380-4565
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156286A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily