Provider Demographics
NPI:1902695018
Name:RANDOLPH, JESSE MARIE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1915
Mailing Address - Country:US
Mailing Address - Phone:260-920-0982
Mailing Address - Fax:
Practice Address - Street 1:101 W DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1915
Practice Address - Country:US
Practice Address - Phone:260-920-0982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician