Provider Demographics
NPI:1629710959
Name:RUSSO, JOHANNA SERENA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:SERENA
Last Name:RUSSO
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 1:3426 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5290
Mailing Address - Country:US
Mailing Address - Phone:517-791-7724
Mailing Address - Fax:
Practice Address - Street 1:3426 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5290
Practice Address - Country:US
Practice Address - Phone:517-791-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula