Provider Demographics
NPI:1790415859
Name:RANDOLPH, JESSICA (BT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5860
Mailing Address - Country:US
Mailing Address - Phone:989-839-2290
Mailing Address - Fax:
Practice Address - Street 1:3301 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-5860
Practice Address - Country:US
Practice Address - Phone:989-839-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician