Provider Demographics
NPI:1962269118
Name:RANDLES, JAYLYN DENISE (CPSW, CHW)
Entity type:Individual
Prefix:MS
First Name:JAYLYN
Middle Name:DENISE
Last Name:RANDLES
Suffix:
Gender:F
Credentials:CPSW, CHW
Other - Prefix:
Other - First Name:JAYLYN
Other - Middle Name:DENISE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPSW
Mailing Address - Street 1:2111 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5600
Mailing Address - Country:US
Mailing Address - Phone:505-879-5655
Mailing Address - Fax:
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-879-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1456175T00000X
NMS3-1615172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist