Provider Demographics
NPI:1093029373
Name:RUSSELL, JENNIE LOU (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LOU
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:LOU
Other - Last Name:ROSSELL-HOWE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-7280
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-0160
Practice Address - Country:US
Practice Address - Phone:505-368-7280
Practice Address - Fax:505-368-6431
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-04576104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
320059Medicare Oscar/Certification