Provider Demographics
NPI:1770459687
Name:RUSSELL, JENNIE (MA)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 JUSTIN MORRILL MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:STRAFFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05072-9763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7145
Practice Address - Country:US
Practice Address - Phone:802-299-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor