Healthcare Provider Details

I. General information

NPI: 1891060620
Provider Name (Legal Business Name): JILLIAN MARIE RUSSELL MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 OLD AIRPORT RD
CONCORD NC
28025-7188
US

IV. Provider business mailing address

1584 DARTMOOR AVE NW
CONCORD NC
28027-3588
US

V. Phone/Fax

Practice location:
  • Phone: 704-933-3781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6742
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: