Provider Demographics
NPI:1720401870
Name:RUSSELL, JAMIE LYNN (DC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8332 SADDLE BROOK DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5654
Mailing Address - Country:US
Mailing Address - Phone:918-284-6184
Mailing Address - Fax:
Practice Address - Street 1:6001 STATE HIGHWAY 317
Practice Address - Street 2:B
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-5464
Practice Address - Country:US
Practice Address - Phone:918-284-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400101653Medicare PIN