Provider Demographics
NPI:1730742107
Name:RUSSELL, JACQUELINE M (DO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8410
Mailing Address - Country:US
Mailing Address - Phone:207-995-0732
Mailing Address - Fax:
Practice Address - Street 1:37 PALMER ST STE 3
Practice Address - Street 2:
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1341
Practice Address - Country:US
Practice Address - Phone:207-454-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO3305207Q00000X, 207Q00000X
CT066286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine