Healthcare Provider Details

I. General information

NPI: 1346024536
Provider Name (Legal Business Name): JERMONTE RUSSELL RUSHING MSW/CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E OSBORN RD
PHOENIX AZ
85012-2327
US

IV. Provider business mailing address

205 E OSBORN RD
PHOENIX AZ
85012-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-556-6229
  • Fax:
Mailing address:
  • Phone: 602-556-6229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberCHW0000000856
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: