Individual
JENNIFER RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
6804 SANGER AVE, #227, WACO, TX 76710-4257
(800) 340-4098
Mailing address
6804 SANGER AVE, #227, WACO, TX 76710-4257
(800) 340-4098
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
403816
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149984001
—
TX
05
—
207164901
—
TX
Enumeration date
10/07/2010
Last updated
10/07/2010
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