Provider Demographics
NPI:1184799876
Name:RUSSELL, JACOB G (LAC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:G
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LAC
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 97
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AR
Mailing Address - Zip Code:72565-0097
Mailing Address - Country:US
Mailing Address - Phone:870-258-3305
Mailing Address - Fax:870-258-3244
Practice Address - Street 1:104 CONNIEBROOK LN
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556-8861
Practice Address - Country:US
Practice Address - Phone:870-258-3305
Practice Address - Fax:870-258-3244
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA1101009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator