Provider Demographics
NPI:1053497065
Name:RUSSELL, JEFFREY ALAN (PT, MS,)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PT, MS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80482-0743
Mailing Address - Country:US
Mailing Address - Phone:970-531-1582
Mailing Address - Fax:
Practice Address - Street 1:116 TRESTLE DRIVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:CO
Practice Address - Zip Code:80482-8048
Practice Address - Country:US
Practice Address - Phone:970-531-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68606770Medicaid
CO68606770Medicaid