Provider Demographics
NPI:1366875015
Name:RUSSELL, JENNIFER RETTE (LPC, RPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RETTE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CAP ROCK DR STE 211
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2306
Mailing Address - Country:US
Mailing Address - Phone:469-708-7650
Mailing Address - Fax:
Practice Address - Street 1:14673 MIDWAY RD
Practice Address - Street 2:SUITE 211
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7500
Practice Address - Country:US
Practice Address - Phone:469-708-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health