Provider Demographics
NPI:1083877310
Name:RUSSELL, JENNIFER LYNN (L M T)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:L M T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9621 MICKELBERRY RD NW STE 108
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8301
Mailing Address - Country:US
Mailing Address - Phone:360-692-5350
Mailing Address - Fax:360-692-5354
Practice Address - Street 1:9621 MICKELBERRY RD NW STE 108
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8301
Practice Address - Country:US
Practice Address - Phone:360-692-5350
Practice Address - Fax:360-692-5354
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist