Basic Information
| Provider Information | |||||||||
| NPI: | 1679154140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 MARSHTREE LN UNIT 301 | ||||||||
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| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283145550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198184876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 W 27TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L005874 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.