Individual
JACQUELYN RUSSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
160 E ERIE AVE, PHILADELPHIA, PA 19134-1011
(215) 427-5000
Mailing address
2530 S MOLE ST, PHILADELPHIA, PA 19145-4606
(484) 477-9599
Taxonomy
Speciality
Code
Description
License number
State
282NC2000X
Children's Hospital
Primary
SP016464
PA
Other
Enumeration date
01/23/2017
Last updated
01/24/2017
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