Individual
JACQUELINE A RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMSW
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
3616
CT
1041C0700X
Clinical Social Worker
Primary
11082
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008023170
—
CT
05
—
008024427
—
CT
05
—
008039745
—
CT
05
—
008042339
—
CT
05
—
008096553
—
CT
01
—
3616
STATE OF CT DPH
CT
Enumeration date
10/10/2017
Last updated
08/06/2020
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