Provider Demographics
NPI:1679068829
Name:RANDALL, JESSICA ANNE (MA, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MA, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNE
Other - Last Name:DIAZ-PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP, TSSLD
Mailing Address - Street 1:251 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1844
Mailing Address - Country:US
Mailing Address - Phone:516-974-6905
Mailing Address - Fax:
Practice Address - Street 1:189 WHEATLEY RD
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-2641
Practice Address - Country:US
Practice Address - Phone:516-626-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X, 390200000X
NY029004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05979424Medicaid