Provider Demographics
NPI:1295182012
Name:RUSSELL, JOANNA NOEL
Entity Type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:NOEL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 W WALNUT ST # 1132
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-1842
Mailing Address - Country:US
Mailing Address - Phone:479-310-5483
Mailing Address - Fax:
Practice Address - Street 1:329 N GARNETT CT APT 6
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-7573
Practice Address - Country:US
Practice Address - Phone:479-310-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR9025-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator