Provider Demographics
NPI:1790948115
Name:RUSSELL, JENNIFER MICHELLE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:HAILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8701 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-2802
Mailing Address - Country:US
Mailing Address - Phone:816-349-3307
Mailing Address - Fax:816-349-3678
Practice Address - Street 1:8701 HOLMES RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-2802
Practice Address - Country:US
Practice Address - Phone:816-349-3307
Practice Address - Fax:816-349-3678
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010707235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist