Provider Demographics
NPI:1568529386
Name:RUSSELL-NISBET, JESSIE KIRKCALDY (LSW)
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:KIRKCALDY
Last Name:RUSSELL-NISBET
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 TARTAN TER
Mailing Address - Street 2:
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-2268
Mailing Address - Country:US
Mailing Address - Phone:215-822-1838
Mailing Address - Fax:
Practice Address - Street 1:512 WEST AVE
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2725
Practice Address - Country:US
Practice Address - Phone:215-885-1835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW012620L101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health