Provider Demographics
NPI:1407447246
Name:RANDALL, JEREMIAH SCOTT (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:SCOTT
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-0202
Mailing Address - Country:US
Mailing Address - Phone:320-223-0467
Mailing Address - Fax:
Practice Address - Street 1:6001 EGAN DR STE 197
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2099
Practice Address - Country:US
Practice Address - Phone:952-592-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8527363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health