Provider Demographics
NPI:1154083061
Name:RANDALL, JESSECA (COTA)
Entity type:Individual
Prefix:
First Name:JESSECA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 FRANKLIN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-0687
Mailing Address - Country:US
Mailing Address - Phone:828-774-9840
Mailing Address - Fax:
Practice Address - Street 1:3800 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2599
Practice Address - Country:US
Practice Address - Phone:910-392-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant