Provider Demographics
NPI:1447571070
Name:RANDALL, JENNA MARIE (MSCCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MSCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6036 E PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2622
Mailing Address - Country:US
Mailing Address - Phone:304-280-5958
Mailing Address - Fax:
Practice Address - Street 1:300 BAKER LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2900
Practice Address - Country:US
Practice Address - Phone:304-345-0867
Practice Address - Fax:304-342-2587
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist