1477302123 NPI number — JENISE ANN RUSSELL CPHT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477302123 NPI number — JENISE ANN RUSSELL CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
JENISE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCOY
Provider Other First Name:
JENISE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPHT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477302123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5471 COUNTY ROAD 3300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEMPNER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76539-5985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-551-2945
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 VETERANS MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-7445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-743-2712
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)