Provider Demographics
NPI:1598494999
Name:RUSSELL, JONATHAN PATRICK
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 PLUM DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49690-9425
Mailing Address - Country:US
Mailing Address - Phone:231-735-6966
Mailing Address - Fax:
Practice Address - Street 1:6063 PLUM DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MI
Practice Address - Zip Code:49690-9425
Practice Address - Country:US
Practice Address - Phone:231-735-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst