Provider Demographics
NPI:1932850179
Name:RANDOLPH, JAMIE LEE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 CHARLES AVE APT 111
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-9220
Mailing Address - Country:US
Mailing Address - Phone:989-763-7382
Mailing Address - Fax:
Practice Address - Street 1:1525 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6425
Practice Address - Country:US
Practice Address - Phone:989-835-6333
Practice Address - Fax:989-835-4920
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician