Provider Demographics
NPI:1588221444
Name:RANDOLPH, JENNIFER (CADC-II, CIP, CAI-II)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CADC-II, CIP, CAI-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 SE MCLOUGHLIN BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7428
Mailing Address - Country:US
Mailing Address - Phone:855-770-0577
Mailing Address - Fax:503-654-1852
Practice Address - Street 1:10600 SE MCLOUGHLIN BLVD STE 207
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7428
Practice Address - Country:US
Practice Address - Phone:855-770-0577
Practice Address - Fax:503-654-1852
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)