Basic Information
| Provider Information | |||||||||
| NPI: | 1497065577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6804 SANGER AVE | ||||||||
| Address2: | #227 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767104257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003404098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6804 SANGER AVE | ||||||||
| Address2: | #227 | ||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767104257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003404098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 403816 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 207164901 | 05 | TX | MEDICAID | 149984001 | 05 | TX | MEDICAID |