Provider Demographics
NPI:1235319880
Name:RUSSELL, JESSE RICHARDS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:RICHARDS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MAQUOIT DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6320
Mailing Address - Country:US
Mailing Address - Phone:207-725-5020
Mailing Address - Fax:207-725-5020
Practice Address - Street 1:10 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1932
Practice Address - Country:US
Practice Address - Phone:207-725-5020
Practice Address - Fax:207-725-5020
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC 53971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME285810099Medicaid
ME285810099Medicaid