Provider Demographics
NPI:1659401990
Name:RUSSO, JESSICA DEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DEAN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S. BROAD ST.
Mailing Address - Street 2:STE 600
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4121
Mailing Address - Country:US
Mailing Address - Phone:215-545-2748
Mailing Address - Fax:215-545-2749
Practice Address - Street 1:230 S. BROAD ST.
Practice Address - Street 2:STE 600
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19102-4121
Practice Address - Country:US
Practice Address - Phone:215-545-2748
Practice Address - Fax:215-545-2749
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015317103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1522333OtherBC/BS
1522333OtherBLUE CROSS BLUE SHIELD
PA155117Medicare PIN