Healthcare Provider Details

I. General information

NPI: 1548831696
Provider Name (Legal Business Name): JESSICA MICHELLE RUSSELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S 5TH ST
PARIS AR
72855-4501
US

IV. Provider business mailing address

303 S 5TH ST
PARIS AR
72855-4501
US

V. Phone/Fax

Practice location:
  • Phone: 479-963-2132
  • Fax:
Mailing address:
  • Phone: 479-963-2132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number216420
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: