Provider Demographics
NPI:1891279584
Name:RUSS, JACQUELINE BLAKE (APRN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BLAKE
Last Name:RUSS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:BLAKE
Other - Last Name:HIX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4123 DUTCHMANS LN STE 307
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4721
Practice Address - Country:US
Practice Address - Phone:502-409-5600
Practice Address - Fax:502-259-3078
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012682363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner