Provider Demographics
NPI:1427187947
Name:JESSEE, RANDALL EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:EDWARD
Last Name:JESSEE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 9054
Mailing Address - Street 2:11675 SPRATLIN PARK DR
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615
Mailing Address - Country:US
Mailing Address - Phone:423-467-3720
Mailing Address - Fax:423-467-3710
Practice Address - Street 1:607 BAXTER ST
Practice Address - Street 2:FAIRVIEW ASSOCIATES
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-232-2670
Practice Address - Fax:423-928-0381
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC90101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor