Provider Demographics
NPI:1912072257
Name:RUSSELL, JEFFREY ALAN (PHD, AT)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SCHOOL OF AHSW, GROVER E182
Mailing Address - Street 2:53 RICHLAND AVE
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-593-4648
Mailing Address - Fax:740-593-0289
Practice Address - Street 1:SHAPE CLINIC, PUTNAM HALL 304
Practice Address - Street 2:96 E UNION ST
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-1829
Practice Address - Fax:740-593-0289
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0000602852255A2300X
OHAT0039982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer