Healthcare Provider Details

I. General information

NPI: 1528922770
Provider Name (Legal Business Name): JENNIFER RUSSO M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-0001
US

IV. Provider business mailing address

155 PLUM CREEK RD
SUNBURY PA
17801-6063
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6211
  • Fax:
Mailing address:
  • Phone: 570-847-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL018658
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: