Individual
JESSICA RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
15 FAIRVIEW AVE, ELLINGTON, CT 06029-4218
(860) 559-7478
(413) 439-0100
Mailing address
15 FAIRVIEW AVE, ELLINGTON, CT 06029-4218
(860) 559-7478
(413) 439-0100
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
12094
CT
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12094
DPH LICENSURE- LCSW
CT
Enumeration date
09/10/2014
Last updated
02/06/2023
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