Healthcare Provider Details

I. General information

NPI: 1841829116
Provider Name (Legal Business Name): MRS. JASMINE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21044 FREDERICK RD
GERMANTOWN MD
20876-4132
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 240-238-5432
  • Fax:
Mailing address:
  • Phone: 804-822-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009717
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008212
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: