MEDICARE: JENNIFER RAE RUSSO DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P13688	NC

General Provider Information

NPI Number	:	1053644930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER RAE RUSSO DPT

Provider Business Mailing Address
First Line	:	4002 1/2 OLEANDER DR STE 102
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6806
Country	:	US
Telephone Number	:	910-216-4887
Fax Number	:	844-704-0649

Provider Business Practice Location Address
First Line	:	4002 1/2 OLEANDER DR STE 102
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6806
Country	:	US
Telephone Number	:	910-216-4887
Fax Number	:	844-704-0649

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	02/18/2026

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