Healthcare Provider Details

I. General information

NPI: 1609082783
Provider Name (Legal Business Name): RANDAL F JACUNSKI MHS,LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-7539
US

IV. Provider business mailing address

250 PLEASANT ST
CONCORD NH
03301-7539
US

V. Phone/Fax

Practice location:
  • Phone: 603-225-2711
  • Fax: 603-227-7169
Mailing address:
  • Phone: 603-225-2711
  • Fax: 603-227-7169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0598
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: