Provider Demographics
NPI:1740328806
Name:RANDALL, JACQUIE Z (MS)
Entity type:Individual
Prefix:MS
First Name:JACQUIE
Middle Name:Z
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E JANSS RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3324
Mailing Address - Country:US
Mailing Address - Phone:805-373-6585
Mailing Address - Fax:
Practice Address - Street 1:25 ROLLING OAKS DR
Practice Address - Street 2:SUITE 204
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1002
Practice Address - Country:US
Practice Address - Phone:805-373-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 29219106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist