MEDICARE: MRS. JENNIFER PERT RUSSO MA CCCSLP

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	235Z00000X	Speech-Language Pathologist	SP765	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	100667	OTHER	ME	ANTHEM BCBS

General Provider Information

NPI Number	:	1760528566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER PERT RUSSO MA CCCSLP

Provider Business Mailing Address
First Line	:	25 WOODRIDGE DR
Second Line	:
City	:	STEEP FALLS
State	:	ME
Zip	:	04085-6860
Country	:	US
Telephone Number	:	207-251-1347
Fax Number	:	207-985-6703

Provider Business Practice Location Address
First Line	:	39 LIMERICK RD
Second Line	:
City	:	ARUNDEL
State	:	ME
Zip	:	04046-8158
Country	:	US
Telephone Number	:	207-391-0331
Fax Number	:	207-985-6703

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	09/08/2023

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Directions to “ MRS. JENNIFER PERT RUSSO MA CCCSLP” Practice Location

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