Healthcare Provider Details

I. General information

NPI: 1043450158
Provider Name (Legal Business Name): MRS. JAMIE D. RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

702 MAIN ST UNIT A
HUNTINGTON BEACH CA
92648-3402
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 714-536-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: