Provider Demographics
NPI:1578290953
Name:RUSSELL, JENNIFER CAROL
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAROL
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 1:18 AUNT PATTYS LN W
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2912
Mailing Address - Country:US
Mailing Address - Phone:203-451-0039
Mailing Address - Fax:
Practice Address - Street 1:887 MAIN ST STE 1B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2800
Practice Address - Country:US
Practice Address - Phone:203-200-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional