1942640008 NPI number — MRS. JORDAN ELIZABETH RANDALL LMHC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942640008 NPI number — MRS. JORDAN ELIZABETH RANDALL LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
JORDAN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OATHOUT
Provider Other First Name:
JORDAN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMHC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1942640008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
146L ARSENAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-343-3344
Provider Business Mailing Address Fax Number:
315-785-5637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
146L ARSENAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-343-3344
Provider Business Practice Location Address Fax Number:
315-785-5637
Provider Enumeration Date:
07/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: P02061 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1942640008 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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