Provider Demographics
NPI:1316735731
Name:RUSSELL, JASON ANDREW (PHD,DRBA, MLS,MBA)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANDREW
Last Name:RUSSELL
Suffix:
Gender:
Credentials:PHD,DRBA, MLS,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33228
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3228
Mailing Address - Country:US
Mailing Address - Phone:212-372-3167
Mailing Address - Fax:
Practice Address - Street 1:215 D AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1300
Practice Address - Country:US
Practice Address - Phone:212-372-3167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty