Healthcare Provider Details

I. General information

NPI: 1720673577
Provider Name (Legal Business Name): JACQUELINE MARIE RUSSELL PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 MEDICAL PKWY
ENTERPRISE OR
97828-5140
US

IV. Provider business mailing address

79571 LEAP LN
WALLOWA OR
97885-7107
US

V. Phone/Fax

Practice location:
  • Phone: 541-426-4524
  • Fax: 541-426-3035
Mailing address:
  • Phone: 503-899-3219
  • Fax: 541-426-3035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10013334
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: