Provider Demographics
NPI:1275191074
Name:RANDOLPH, JESSICA (CNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5965 E BROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1562
Mailing Address - Country:US
Mailing Address - Phone:614-234-8860
Mailing Address - Fax:
Practice Address - Street 1:5965 E BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1562
Practice Address - Country:US
Practice Address - Phone:614-234-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily