Provider Demographics
NPI:1679248793
Name:RUSSELL, JENNIFER RENEE (CO7A/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CO7A/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 DEWEY DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:WALLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37886
Mailing Address - Country:US
Mailing Address - Phone:865-221-2125
Mailing Address - Fax:
Practice Address - Street 1:1 VETERAN'S WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931
Practice Address - Country:US
Practice Address - Phone:865-862-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3201224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant