Provider Demographics
NPI:1790481588
Name:RUSS, JADA NICOLE
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:NICOLE
Last Name:RUSS
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 1:2601 ROOSEVELT HWY APT L8
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-6219
Mailing Address - Country:US
Mailing Address - Phone:470-786-2011
Mailing Address - Fax:
Practice Address - Street 1:2601 ROOSEVELT HWY APT L8
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-6219
Practice Address - Country:US
Practice Address - Phone:470-786-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician