Provider Demographics
NPI:1750860458
Name:RUSSO, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-2220
Mailing Address - Country:US
Mailing Address - Phone:617-874-0765
Mailing Address - Fax:
Practice Address - Street 1:120 SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-2650
Practice Address - Country:US
Practice Address - Phone:617-633-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9508225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant