Provider Demographics
NPI:1093206021
Name:RUSSELL, JESSICA ELLEN LEVONN (DH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN LEVONN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:LEVONN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:
Practice Address - Street 1:626 2ND AVE S
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00007140124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist