Provider Demographics
NPI:1992503718
Name:RUSSELL, JARED T
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:T
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 NANCY LN
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1164
Mailing Address - Country:US
Mailing Address - Phone:304-991-7711
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV123379367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty