Provider Demographics
NPI:1801041124
Name:RUSSELL, JERELYN S
Entity Type:Individual
Prefix:MRS
First Name:JERELYN
Middle Name:S
Last Name:RUSSELL
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 1:117 N VANDERHORST ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-1324
Mailing Address - Country:US
Mailing Address - Phone:803-718-3121
Mailing Address - Fax:803-815-0403
Practice Address - Street 1:1077 KINCAID BRIDGE RD.
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180
Practice Address - Country:US
Practice Address - Phone:803-635-9416
Practice Address - Fax:803-815-0403
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101Y00000X101Y00000X
SC172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor