Healthcare Provider Details

I. General information

NPI: 1407200413
Provider Name (Legal Business Name): JENNIFER RUSSO RN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 E TOMPKINS AVE STE 100
LAS VEGAS NV
89121-7394
US

IV. Provider business mailing address

83 KIND AVE
HENDERSON NV
89002-3364
US

V. Phone/Fax

Practice location:
  • Phone: 725-724-2005
  • Fax: 877-418-8013
Mailing address:
  • Phone: 702-824-7691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberRN55131
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG167246
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number238538
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number848206
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202203390-NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: