Healthcare Provider Details

I. General information

NPI: 1760510192
Provider Name (Legal Business Name): JESSICA RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 POSA PLACE
DARTMOUTH MA
02747-2511
US

IV. Provider business mailing address

1217 HOPE ST
BRISTOL RI
02809-1125
US

V. Phone/Fax

Practice location:
  • Phone: 508-996-3391
  • Fax:
Mailing address:
  • Phone: 401-396-9023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15527
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: