Provider Demographics
NPI:1942640008
Name:RANDALL, JORDAN ELIZABETH (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:JORDAN
Other - Middle Name:ELIZABETH
Other - Last Name:OATHOUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:146L ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-343-3344
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:146L ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-343-3344
Practice Address - Fax:315-785-5637
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NYP02061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1942640008Medicaid