Provider Demographics
NPI:1073975934
Name:RUSSO, JENNIFER LYNN (LPC, LCADC, ACS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LPC, LCADC, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 STILLWATER RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07825-9554
Mailing Address - Country:US
Mailing Address - Phone:908-310-4323
Mailing Address - Fax:
Practice Address - Street 1:13 STILLWATER RD
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825-9554
Practice Address - Country:US
Practice Address - Phone:908-310-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00571300101YM0800X
NJ37LC00239900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)