Provider Demographics
NPI:1073117206
Name:RANDALL, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 PERIDOT ST
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-8391
Mailing Address - Country:US
Mailing Address - Phone:614-204-8663
Mailing Address - Fax:
Practice Address - Street 1:6010 PERIDOT ST
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-8391
Practice Address - Country:US
Practice Address - Phone:614-204-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemaker