Basic Information
| Provider Information | |||||||||
| NPI: | 1679885602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 COMMERCE AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400660 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 3770 GLENKERRY CT | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490240700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693292887 | ||||||||
| FaxNumber: | 2693292805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 07/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014496 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.