Provider Demographics
NPI:1922406859
Name:RUSSELL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:21907 TOSCANA CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-0919
Mailing Address - Country:US
Mailing Address - Phone:405-623-2326
Mailing Address - Fax:
Practice Address - Street 1:12777 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2710
Practice Address - Country:US
Practice Address - Phone:405-717-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK94676364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health