MEDICARE: MARY JESSICA RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula	124148987	NM

General Provider Information

NPI Number	:	1427843440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JESSICA RUSSELL

Provider Business Mailing Address
First Line	:	PO BOX 2131
Second Line	:
City	:	MESILLA PARK
State	:	NM
Zip	:	88047-2131
Country	:	US
Telephone Number	:	575-499-9548
Fax Number	:

Provider Business Practice Location Address
First Line	:	940 LOPEZ RD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-6806
Country	:	US
Telephone Number	:	575-499-9548
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2025
Last Update Date	:	04/10/2025

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