Provider Demographics
NPI:1124865944
Name:RUSSELL, JENIFER LYNN (RADT)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 SAMS HILL RD APT 13
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-3075
Mailing Address - Country:US
Mailing Address - Phone:858-717-6858
Mailing Address - Fax:
Practice Address - Street 1:1733 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5414
Practice Address - Country:US
Practice Address - Phone:619-263-0433
Practice Address - Fax:614-926-3399
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)