Provider Demographics
NPI:1972104735
Name:RUSSELL, JESSIE LEE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:LEE
Other - Last Name:SCHROPPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 S ALASKA ST STE 202
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6372
Mailing Address - Country:US
Mailing Address - Phone:907-746-6019
Mailing Address - Fax:907-745-7565
Practice Address - Street 1:550 S ALASKA ST STE 202
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6372
Practice Address - Country:US
Practice Address - Phone:907-746-6019
Practice Address - Fax:907-745-7565
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1811042872Medicaid