Healthcare Provider Details

I. General information

NPI: 1366293946
Provider Name (Legal Business Name): JAYE B RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7492 SOQUEL DR STE F
APTOS CA
95003-3857
US

IV. Provider business mailing address

1111 PLEASANT VALLEY RD
APTOS CA
95003-9714
US

V. Phone/Fax

Practice location:
  • Phone: 831-239-9806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number9873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: