Provider Demographics
NPI:1275151771
Name:RUSSELL, JOHNNA (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:JOHNNA
Other - Middle Name:
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4304 S BEARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-9557
Mailing Address - Country:US
Mailing Address - Phone:844-424-3577
Mailing Address - Fax:
Practice Address - Street 1:4304 S BEARFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-9557
Practice Address - Country:US
Practice Address - Phone:844-424-3577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200141471041C0700X
MO20230112521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical