Healthcare Provider Details

I. General information

NPI: 1922406859
Provider Name (Legal Business Name): JENNIFER RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12777 N ROCKWELL AVE
OKLAHOMA CITY OK
73142-2710
US

IV. Provider business mailing address

21907 TOSCANA CT
EDMOND OK
73012-0919
US

V. Phone/Fax

Practice location:
  • Phone: 405-717-7740
  • Fax:
Mailing address:
  • Phone: 405-623-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number94676
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: