Provider Demographics
NPI:1730707480
Name:RANDALL, JEFFREY BLAINE (CDCA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAINE
Last Name:RANDALL
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4867 URBANA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502
Mailing Address - Country:US
Mailing Address - Phone:937-971-7358
Mailing Address - Fax:937-717-5995
Practice Address - Street 1:4867 URBANA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502
Practice Address - Country:US
Practice Address - Phone:937-971-7358
Practice Address - Fax:937-717-5995
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172965101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)