Provider Demographics
NPI:1457143513
Name:RUSSELL, JONATHAN H (LPCA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:H
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06779-1438
Mailing Address - Country:US
Mailing Address - Phone:914-539-5993
Mailing Address - Fax:
Practice Address - Street 1:268 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06779-1438
Practice Address - Country:US
Practice Address - Phone:914-539-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health