Provider Demographics
NPI:1710436506
Name:RUSSELL, JAMIE GORDON
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:GORDON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2005 OAK RIVER ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6706
Mailing Address - Country:US
Mailing Address - Phone:702-279-8124
Mailing Address - Fax:
Practice Address - Street 1:2005 OAK RIVER ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-6706
Practice Address - Country:US
Practice Address - Phone:702-279-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15-0541225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist