Provider Demographics
NPI:1487194627
Name:RANDT, JENNIFER LYNNE
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:RANDT
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 1:934 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3124
Mailing Address - Country:US
Mailing Address - Phone:650-219-5689
Mailing Address - Fax:
Practice Address - Street 1:3036 REGENT ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2551
Practice Address - Country:US
Practice Address - Phone:650-219-5689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125941106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist