Provider Demographics
NPI:1861734030
Name:RUSSELL, JILLIAN JULIA (NP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:JULIA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5224
Mailing Address - Country:US
Mailing Address - Phone:508-853-2854
Mailing Address - Fax:508-853-4354
Practice Address - Street 1:939 SOUTHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2227
Practice Address - Country:US
Practice Address - Phone:508-860-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN265677363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health