Provider Demographics
NPI:1417610189
Name:RANDOLPH, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:RANDOLPH
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 1:375 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1199
Mailing Address - Country:US
Mailing Address - Phone:801-844-1615
Mailing Address - Fax:
Practice Address - Street 1:375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1199
Practice Address - Country:US
Practice Address - Phone:801-844-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical