Provider Demographics
NPI:1497045033
Name:RUSSELL, JENNIFER ANN (MA, CAGS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BARCLAY ST
Mailing Address - Street 2:#2
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4207
Mailing Address - Country:US
Mailing Address - Phone:508-459-0295
Mailing Address - Fax:
Practice Address - Street 1:13 BARCLAY ST
Practice Address - Street 2:#2
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4207
Practice Address - Country:US
Practice Address - Phone:508-459-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-17
Last Update Date:2011-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health