Provider Demographics
NPI:1376380964
Name:RUSSELL, JENNIFER LYNN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
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 1:414 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2217
Mailing Address - Country:US
Mailing Address - Phone:937-367-2566
Mailing Address - Fax:
Practice Address - Street 1:694 ISAAC PRUGH WAY
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3481
Practice Address - Country:US
Practice Address - Phone:937-367-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-5491235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist