Provider Demographics
NPI:1699462150
Name:RANDOLPH, JORDYN NOELLE
Entity type:Individual
Prefix:MS
First Name:JORDYN
Middle Name:NOELLE
Last Name:RANDOLPH
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 1:930 E ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4053
Mailing Address - Country:US
Mailing Address - Phone:714-908-6899
Mailing Address - Fax:
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:714-908-6899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program