Provider Demographics
NPI:1205986858
Name:RUSSELL, JENNIFER S (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-875-8032
Mailing Address - Fax:813-875-0227
Practice Address - Street 1:13005 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7439
Practice Address - Country:US
Practice Address - Phone:813-875-8032
Practice Address - Fax:813-875-0227
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology