Healthcare Provider Details

I. General information

NPI: 1780967166
Provider Name (Legal Business Name): JODI LYNN RUSSELL MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 BROADCASTING RD SUITE 201
WYOMISSING PA
19610-3229
US

IV. Provider business mailing address

1350 BROADCASTING RD SUITE 201
WYOMISSING PA
19610-3229
US

V. Phone/Fax

Practice location:
  • Phone: 610-685-9600
  • Fax: 610-685-6700
Mailing address:
  • Phone: 610-685-9600
  • Fax: 610-685-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004416
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: