Healthcare Provider Details

I. General information

NPI: 1205773462
Provider Name (Legal Business Name): RANDALL JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 3RD AVE NE
BELFIELD ND
58622-7219
US

IV. Provider business mailing address

501 3RD AVE NE
BELFIELD ND
58622-7219
US

V. Phone/Fax

Practice location:
  • Phone: 701-339-7439
  • Fax:
Mailing address:
  • Phone: 701-339-7439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: