Healthcare Provider Details

I. General information

NPI: 1114347846
Provider Name (Legal Business Name): JENNIFER RUSSELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

IV. Provider business mailing address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-2000
  • Fax: 318-424-2601
Mailing address:
  • Phone: 318-425-2000
  • Fax: 318-424-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35083
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1399
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: