| NPI | 1801804935 |
|---|---|
| Professional Name | JACK RUSSELL |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 79043703N6) |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2007-07-26 |