Provider Demographics
NPI:1851956528
Name:JAFFE, RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:JAFFE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13304 W STELLA LN
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-5387
Mailing Address - Country:US
Mailing Address - Phone:602-619-3779
Mailing Address - Fax:
Practice Address - Street 1:4050 E COTTON CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-8861
Practice Address - Country:US
Practice Address - Phone:480-795-7330
Practice Address - Fax:602-296-5622
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-003354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist