Healthcare Provider Details

I. General information

NPI: 1265944979
Provider Name (Legal Business Name): JANNELL CHAKAKHAN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 S OLIVE ST
LOS ANGELES CA
90015-3023
US

IV. Provider business mailing address

1530 S OLIVE ST
LOS ANGELES CA
90015-3023
US

V. Phone/Fax

Practice location:
  • Phone: 213-747-5542
  • Fax: 213-746-9379
Mailing address:
  • Phone: 213-747-5542
  • Fax: 213-746-9379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number9214052
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95030098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: