Healthcare Provider Details

I. General information

NPI: 1861465361
Provider Name (Legal Business Name): JENNIFER RAGAN RUSSELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

7125 13TH PL NW
WASHINGTON DC
20012
US

V. Phone/Fax

Practice location:
  • Phone: 917-855-9957
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4715
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDO210012353
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License NumberDO210012353
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: