Provider Demographics
NPI:1659040590
Name:RUSSELL, JESSE DAVID WINSLOW (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID WINSLOW
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15616 S WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-9255
Mailing Address - Country:US
Mailing Address - Phone:971-404-4586
Mailing Address - Fax:
Practice Address - Street 1:345 N GRANT ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3689
Practice Address - Country:US
Practice Address - Phone:503-266-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA203927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine