Provider Demographics
NPI:1053644930
Name:RUSSO, JENNIFER RAE (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 ALLENS LN STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3662
Mailing Address - Country:US
Mailing Address - Phone:910-256-4442
Mailing Address - Fax:910-256-4443
Practice Address - Street 1:1721 ALLENS LN STE 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3662
Practice Address - Country:US
Practice Address - Phone:910-256-4442
Practice Address - Fax:910-256-4443
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13688225100000X
OHPT.012148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist