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NPI Code Detail

MEDICARE: JESSICA D. RUSSELL M. ED, LPCA

MEDICARE: JESSICA D. RUSSELL M. ED, LPCA
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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1285158006
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA D. RUSSELL M. ED, LPCA
Provider Business Mailing Address
First Line : 280 EXECUTIVE PARK DR STE 100
Second Line :
City : CONCORD
State : NC
Zip : 28025-1838
Country : US
Telephone Number : 704-786-8220
Fax Number :
Provider Business Practice Location Address
First Line : 280 EXECUTIVE PARK DR STE 100
Second Line :
City : CONCORD
State : NC
Zip : 28025-1838
Country : US
Telephone Number : 704-786-8220
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2017
Last Update Date : 07/21/2022

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