Provider Demographics
NPI:1659040590
Name:RUSSELL, JESSE DAVID WINSLOW (PA-C)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID WINSLOW
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:1185 S ELM ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3935
Practice Address - Country:US
Practice Address - Phone:503-723-4660
Practice Address - Fax:503-266-6649
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORPA203927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine