Provider Demographics
NPI:1356437024
Name:RUSSELL, JENNY S
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0579
Mailing Address - Country:US
Mailing Address - Phone:573-663-7529
Mailing Address - Fax:
Practice Address - Street 1:115 WALNUT ST.
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638
Practice Address - Country:US
Practice Address - Phone:573-663-3177
Practice Address - Fax:573-663-3188
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant