Provider Demographics
NPI:1043409915
Name:RUSSMAN, JEANINE RENEE (DPT)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:RENEE
Last Name:RUSSMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:RENEE
Other - Last Name:MCBRIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2256
Mailing Address - Fax:704-323-3911
Practice Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2387
Practice Address - Country:US
Practice Address - Phone:704-323-3208
Practice Address - Fax:704-323-3911
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist