Provider Demographics
NPI:1639156268
Name:RUSSELL, JACQUELYN KAY (PA)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:KAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 EMBRETSON ROAD
Mailing Address - Street 2:
Mailing Address - City:ILIAMNA
Mailing Address - State:AK
Mailing Address - Zip Code:99606
Mailing Address - Country:US
Mailing Address - Phone:907-744-8581
Mailing Address - Fax:
Practice Address - Street 1:101 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:ILIAMNA
Practice Address - State:AK
Practice Address - Zip Code:99606
Practice Address - Country:US
Practice Address - Phone:907-571-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2024-09-06
Deactivation Date:2024-08-16
Deactivation Code:
Reactivation Date:2024-08-30
Provider Licenses
StateLicense IDTaxonomies
IL085.004670363A00000X
NY023071363A00000X
AKPADA481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639156268OtherNPI
NY1639156268Medicaid