Provider Demographics
NPI:1396934196
Name:RUSSELL, JONATHAN FORREST (PA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:FORREST
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-6571
Mailing Address - Country:US
Mailing Address - Phone:541-492-4550
Mailing Address - Fax:541-492-4553
Practice Address - Street 1:671 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-6571
Practice Address - Country:US
Practice Address - Phone:541-492-4550
Practice Address - Fax:541-679-2005
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR161337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZFQ31815OtherMEDICARE
03-1820OtherMEDICARE
ZFQ31820OtherMEDICARE
Z139132OtherMEDICARE
03-1815OtherMEDICARE
AZ364775Medicaid
Z132429OtherMEDICARE