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General NPI Number Information
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NPI Number | 1992131817
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Entity Type | Individual
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Provider Name | JESSICA ANN RUSSELL DAT, MS, ATC, CSCS
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Gender | Female
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Dates
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Enumeration Date | 09/24/2013
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Last Update Date | 05/28/2021
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Provider Practice Location Address
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Address Line | 1851 SCHOETTLER RD
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City | CHESTERFIELD
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State | MO
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Zip | 63017-5597
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Country | US
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Telephone | 636-230-1756
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Fax |
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Provider Business Mailing Address
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Address Line | 5806 RIVERFRONT DR
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City | PALMYRA
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State | NJ
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Zip | 08065-2146
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Country | US
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Telephone | 989-415-2213
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT005272
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2021013345
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License Number State | MO
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