Provider Demographics
NPI:1972162683
Name:RUSSELL, JAI KIERON RENE (LCSW)
Entity Type:Individual
Prefix:
First Name:JAI
Middle Name:KIERON RENE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-0385
Mailing Address - Country:US
Mailing Address - Phone:206-930-8970
Mailing Address - Fax:
Practice Address - Street 1:2135 CHARLOTTE ST STE 2
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2741
Practice Address - Country:US
Practice Address - Phone:206-930-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-380381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical