Healthcare Provider Details

I. General information

NPI: 1982540027
Provider Name (Legal Business Name): JACOB DAVID RANDOLPH DNP, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 N COVE BLVD
TOLEDO OH
43606-3895
US

IV. Provider business mailing address

2142 N COVE BLVD
TOLEDO OH
43606-3895
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-4491
  • Fax: 419-479-6030
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0021559
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: