Provider Demographics
NPI:1134276173
Name:RUSSELL, JENNIFER M (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMFT
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 62
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-0062
Mailing Address - Country:US
Mailing Address - Phone:651-492-4834
Mailing Address - Fax:651-344-1966
Practice Address - Street 1:2249 OAK GLEN DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9631
Practice Address - Country:US
Practice Address - Phone:651-492-4834
Practice Address - Fax:651-344-1966
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1359106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116942OtherHEALTHPARTNERS
MN78G84INOtherBLUECROSS BLUE SHIELD
MN78G85RUOtherBLUECROSS BLUE SHIELD
MN735398700OtherMHCP