Provider Demographics
NPI:1316577141
Name:JENNIFER L RUSSELL, PSYCHOLOGIST, LLC
Entity Type:Organization
Organization Name:JENNIFER L RUSSELL, PSYCHOLOGIST, LLC
Other - Org Name:CLINICAL & FORENSIC PSYCHOLOGY OF SHREVEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-685-9148
Mailing Address - Street 1:2800 YOUREE DR STE 369
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3646
Mailing Address - Country:US
Mailing Address - Phone:318-685-9148
Mailing Address - Fax:318-693-0103
Practice Address - Street 1:2800 YOUREE DR STE 369
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3646
Practice Address - Country:US
Practice Address - Phone:318-685-9148
Practice Address - Fax:318-693-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty