Provider Demographics
NPI:1992131817
Name:RUSSELL, JESSICA ANN (DAT, MS, ATC, CSCS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DAT, MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5806 RIVERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NJ
Mailing Address - Zip Code:08065-2146
Mailing Address - Country:US
Mailing Address - Phone:989-415-2213
Mailing Address - Fax:
Practice Address - Street 1:1851 SCHOETTLER RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5597
Practice Address - Country:US
Practice Address - Phone:636-230-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0052722255A2300X
MO20210133452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer