Provider Demographics
NPI:1720869613
Name:RUSSELL, JESSICA MARIE (CADAC II)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CADAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1972 KNOX DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:IN
Mailing Address - Zip Code:46118-9485
Mailing Address - Country:US
Mailing Address - Phone:317-654-8315
Mailing Address - Fax:
Practice Address - Street 1:1972 KNOX DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:IN
Practice Address - Zip Code:46118-9485
Practice Address - Country:US
Practice Address - Phone:317-654-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC2-51276101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)