Healthcare Provider Details

I. General information

NPI: 1386288942
Provider Name (Legal Business Name): JENEILLE RUSSELL BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 SHOEMAKER RD STE 230
KING OF PRUSSIA PA
19406-4238
US

IV. Provider business mailing address

583 SHOEMAKER RD STE 230
KING OF PRUSSIA PA
19406-4238
US

V. Phone/Fax

Practice location:
  • Phone: 484-681-2170
  • Fax: 484-320-8307
Mailing address:
  • Phone: 484-681-2170
  • Fax: 484-320-8307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-78214
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: