Healthcare Provider Details

I. General information

NPI: 1255696449
Provider Name (Legal Business Name): JESSICA RUSSELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 N BLOUNT ST
RALEIGH NC
27604-1124
US

IV. Provider business mailing address

3064 WAKE FOREST RD # 1365
RALEIGH NC
27609-7844
US

V. Phone/Fax

Practice location:
  • Phone: 919-213-1029
  • Fax:
Mailing address:
  • Phone: 919-297-8343
  • Fax: 919-213-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226111
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5005735
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226111
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: