Provider Demographics
NPI:1841768553
Name:RUSSOM, ASHLEY LYNN
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:RUSSOM
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 1:2707 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7213
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:28 SOUTHPOINTE DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-6238
Practice Address - Country:US
Practice Address - Phone:870-239-2244
Practice Address - Fax:870-236-1616
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor