Provider Demographics
NPI:1083356059
Name:MCLEAN-RUSS, JENNIFER INEZ (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:INEZ
Last Name:MCLEAN-RUSS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 GRAMMERCY PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2887
Mailing Address - Country:US
Mailing Address - Phone:919-908-8370
Mailing Address - Fax:984-278-6614
Practice Address - Street 1:505 GRAMMERCY PL
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2887
Practice Address - Country:US
Practice Address - Phone:919-908-8370
Practice Address - Fax:984-278-6614
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016126363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty