Provider Demographics
NPI:1174842215
Name:RANDOLPH, JESSICA (LPC, PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LPC, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3100
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK3205363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health