MEDICARE: JENNIFER RUSSO PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	231237	LA

General Provider Information

NPI Number	:	1487331955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER RUSSO PMHNP

Provider Business Mailing Address
First Line	:	1045 JOE MOUTON RD
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-6225
Country	:	US
Telephone Number	:	337-278-3151
Fax Number	:

Provider Business Practice Location Address
First Line	:	406 SAINT JULIEN AVE
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4622
Country	:	US
Telephone Number	:	337-366-6050
Fax Number	:	337-366-6051

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

Provider Enumeration Date	:	06/28/2023
Last Update Date	:	06/28/2023

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