Provider Demographics
NPI:1659028108
Name:RUSSELL, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2209
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70459-2209
Mailing Address - Country:US
Mailing Address - Phone:985-649-2700
Mailing Address - Fax:985-649-8488
Practice Address - Street 1:1810 LINDBERG DR STE 2100
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8160
Practice Address - Country:US
Practice Address - Phone:985-649-2700
Practice Address - Fax:985-649-2950
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner