Provider Demographics
NPI:1760528566
Name:RUSSO, JENNIFER PERT (MA CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:PERT
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JILL
Other - Last Name:PERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:25 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:STEEP FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04085-6860
Mailing Address - Country:US
Mailing Address - Phone:207-251-1347
Mailing Address - Fax:207-985-6703
Practice Address - Street 1:39 LIMERICK RD
Practice Address - Street 2:
Practice Address - City:ARUNDEL
Practice Address - State:ME
Practice Address - Zip Code:04046-8158
Practice Address - Country:US
Practice Address - Phone:207-391-0331
Practice Address - Fax:207-985-6703
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP765235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME252300099Medicaid
ME100667OtherANTHEM BCBS