Provider Demographics
NPI:1982189247
Name:RUSSELL, JAIZANE ALEXIS
Entity Type:Individual
Prefix:MS
First Name:JAIZANE
Middle Name:ALEXIS
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 1:286 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1604
Mailing Address - Country:US
Mailing Address - Phone:937-818-9506
Mailing Address - Fax:
Practice Address - Street 1:30 NORTHWEST AVE STE 120
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1808
Practice Address - Country:US
Practice Address - Phone:330-633-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OHS.1903283104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician