Healthcare Provider Details

I. General information

NPI: 1801041124
Provider Name (Legal Business Name): MRS. JERELYN S RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 KINCAID BRIDGE RD.
WINNSBORO SC
29180
US

IV. Provider business mailing address

117 N VANDERHORST ST
WINNSBORO SC
29180-1324
US

V. Phone/Fax

Practice location:
  • Phone: 803-635-9416
  • Fax: 803-815-0403
Mailing address:
  • Phone: 803-718-3121
  • Fax: 803-815-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101Y00000X
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number172V00000X
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: