Provider Demographics
NPI:1881300861
Name:RUSSELL, JACOB A
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4713 GLANSTONBURY DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-8654
Mailing Address - Country:US
Mailing Address - Phone:614-592-4670
Mailing Address - Fax:
Practice Address - Street 1:2200 13TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2215
Practice Address - Country:US
Practice Address - Phone:605-892-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist