Healthcare Provider Details

I. General information

NPI: 1093635625
Provider Name (Legal Business Name): JONAH RANDALL BURRELL DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1483 TOBIAS GADSON BLVD
CHARLESTON SC
29407-8702
US

IV. Provider business mailing address

1483 TOBIAS GADSON BLVD
CHARLESTON SC
29407-8702
US

V. Phone/Fax

Practice location:
  • Phone: 312-981-9808
  • Fax:
Mailing address:
  • Phone: 312-981-9808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number32222
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: