Provider Demographics
NPI:1548826001
Name:RUSSELL, JEWEL
Entity type:Individual
Prefix:MS
First Name:JEWEL
Middle Name:
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 1:78 DOODLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-8201
Mailing Address - Country:US
Mailing Address - Phone:803-535-9653
Mailing Address - Fax:803-874-2660
Practice Address - Street 1:78 DOODLE HILL RD
Practice Address - Street 2:
Practice Address - City:SAINT MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-8201
Practice Address - Country:US
Practice Address - Phone:803-535-9653
Practice Address - Fax:803-874-2660
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator