Provider Demographics
NPI:1518409028
Name:RANDAZZO, JESSICA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 TUSQUITTEE LAUREL DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAYESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 SATELLITE BLVD.
Practice Address - Street 2:SUITE 2250
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006590225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist