Provider Demographics
NPI:1063021673
Name:RANDOLPH, JENNA ANN (SLP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2895 GREYSTONE LN APT 7
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8450
Mailing Address - Country:US
Mailing Address - Phone:989-824-1148
Mailing Address - Fax:
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-2000
Practice Address - Country:US
Practice Address - Phone:989-824-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist