Provider Demographics
NPI:1760028518
Name:RANDOLPH, JAKEISHIA
Entity Type:Individual
Prefix:
First Name:JAKEISHIA
Middle Name:
Last Name:RANDOLPH
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 1:693 LEESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2828
Mailing Address - Country:US
Mailing Address - Phone:434-200-5750
Mailing Address - Fax:434-237-1737
Practice Address - Street 1:693 LEESVILLE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2828
Practice Address - Country:US
Practice Address - Phone:434-200-5750
Practice Address - Fax:434-237-1737
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician