Provider Demographics
NPI:1578748679
Name:JEFFRIES, RANDALL THOMAS
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:THOMAS
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-2412
Mailing Address - Country:US
Mailing Address - Phone:559-274-0299
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-274-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100444OtherSTAFF ID NUMBER