Healthcare Provider Details

I. General information

NPI: 1598819633
Provider Name (Legal Business Name): JERI SUSAN RUSSELL-AIELLO R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 BURLINGTON AVE
WESTERN SPRINGS IL
60558-1516
US

IV. Provider business mailing address

611 WENONAH AVE
OAK PARK IL
60304-1031
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-0826
  • Fax:
Mailing address:
  • Phone: 708-524-1646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: