Provider Demographics
NPI:1093382194
Name:RUSSELL, JONATHAN NICHOLAS
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NICHOLAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 SOLEDAD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3534
Mailing Address - Country:US
Mailing Address - Phone:831-512-4058
Mailing Address - Fax:
Practice Address - Street 1:7500 ARROYO CIR STE 180
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-7339
Practice Address - Country:US
Practice Address - Phone:408-859-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst