MEDICARE: JESSICA ANNE RANDALL MA, CCC-SLP, TSSLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist
2	390200000X	Student in an Organized Health Care Education/Training Program
3	235Z00000X	Speech-Language Pathologist	029004	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679068829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANNE RANDALL MA, CCC-SLP, TSSLD

Provider Business Mailing Address
First Line	:	251 BROADWAY
Second Line	:
City	:	MASSAPEQUA PARK
State	:	NY
Zip	:	11762-1844
Country	:	US
Telephone Number	:	516-974-6905
Fax Number	:

Provider Business Practice Location Address
First Line	:	507 DEER PARK RD
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-5207
Country	:	US
Telephone Number	:	631-549-4900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	06/07/2025

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