MEDICARE: MR. JACOB DAVID RANDOLPH BSN, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1982540027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB DAVID RANDOLPH BSN, RN

Provider Business Mailing Address
First Line	:	3845 ELMHURST RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-4209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2142 N COVE BLVD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-3895
Country	:	US
Telephone Number	:	419-291-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2026
Last Update Date	:	04/28/2026

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