Healthcare Provider Details

I. General information

NPI: 1922044270
Provider Name (Legal Business Name): JEFFREY D. RUSSELL AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4159
  • Fax: 910-450-4194
Mailing address:
  • Phone: 910-450-4159
  • Fax: 910-450-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY 941
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License NumberAY941
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAY941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: