Provider Demographics
NPI:1740899889
Name:RANDALL, JENEE DANIELLE
Entity type:Individual
Prefix:
First Name:JENEE
Middle Name:DANIELLE
Last Name:RANDALL
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 1:816 RIVER TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:NC
Mailing Address - Zip Code:28098-1279
Mailing Address - Country:US
Mailing Address - Phone:704-868-6909
Mailing Address - Fax:
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-4666
Practice Address - Fax:704-824-3666
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician