Provider Demographics
NPI:1194267419
Name:RUSSELL, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:HI RLS MTN PK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0553
Mailing Address - Country:US
Mailing Address - Phone:575-443-6166
Mailing Address - Fax:575-437-0755
Practice Address - Street 1:1301 OREGON AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5710
Practice Address - Country:US
Practice Address - Phone:575-443-6166
Practice Address - Fax:575-437-0755
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1601116104100000X
NMC-111181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker