Provider Demographics
NPI:1750457594
Name:RUSSELL, JOLENE R (BA LMP)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BA LMP
Other - Prefix:
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Mailing Address - Street 1:2417 PACIFIC AVE SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501
Mailing Address - Country:US
Mailing Address - Phone:360-528-8559
Mailing Address - Fax:360-528-6827
Practice Address - Street 1:2417 PACIFIC AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:360-528-8559
Practice Address - Fax:360-528-6827
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMA00014052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist