Provider Demographics
NPI:1205518297
Name:RUSSO, JENNIFER (LSC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:LSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GRANDE BLVD SE STE B
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1695
Mailing Address - Country:US
Mailing Address - Phone:505-218-6383
Mailing Address - Fax:505-636-6338
Practice Address - Street 1:2200 GRANDE BLVD SE STE B
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1695
Practice Address - Country:US
Practice Address - Phone:505-218-6383
Practice Address - Fax:505-636-6338
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM329851101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool