Provider Demographics
NPI:1568722031
Name:RANDALL, JILL A (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:A
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W CULTON ST
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-1517
Mailing Address - Country:US
Mailing Address - Phone:203-809-5274
Mailing Address - Fax:
Practice Address - Street 1:520 BURKARTH RD STE C
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3123
Practice Address - Country:US
Practice Address - Phone:203-809-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012012905101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health