Provider Demographics
NPI:1841795945
Name:RUSSELL, JAMAL
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 E GEORGIA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3901
Mailing Address - Country:US
Mailing Address - Phone:318-242-0730
Mailing Address - Fax:
Practice Address - Street 1:829 E GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3912
Practice Address - Country:US
Practice Address - Phone:318-242-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health