Provider Demographics
NPI:1447944954
Name:RANDALL, JENNIFER (PMHNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MCKNIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4310 METRO PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:239-790-2624
Practice Address - Street 1:4310 METRO PKWY STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9416
Practice Address - Country:US
Practice Address - Phone:833-362-7935
Practice Address - Fax:239-561-2933
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026542363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health