Provider Demographics
NPI:1497065577
Name:RUSSELL, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6804 SANGER AVE
Mailing Address - Street 2:#227
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4257
Mailing Address - Country:US
Mailing Address - Phone:800-340-4098
Mailing Address - Fax:
Practice Address - Street 1:6804 SANGER AVE
Practice Address - Street 2:#227
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4257
Practice Address - Country:US
Practice Address - Phone:800-340-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX403816224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN
TX149984001Medicaid