Individual
JUSTIN JAKE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
L.M.P.
Contact information
Practice address
22470 HUMPHREY DR, LEAVENWORTH, WA 98826-9240
(253) 389-7510
Mailing address
PO BOX 475, LEAVENWORTH, WA 98826-0475
(253) 389-7510
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA00024875
WA
Other
Enumeration date
01/14/2008
Last updated
08/14/2008
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