Provider Demographics
NPI:1619257763
Name:RUSSELL, JASON THOMAS
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
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 1:7013 ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-3001
Mailing Address - Country:US
Mailing Address - Phone:901-491-2100
Mailing Address - Fax:
Practice Address - Street 1:847 MONROE AVE
Practice Address - Street 2:SUITE 226
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-4901
Practice Address - Country:US
Practice Address - Phone:901-448-6036
Practice Address - Fax:901-448-7053
Is Sole Proprietor?:No
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program