Provider Demographics
NPI:1871372094
Name:JANSEN, RANDELLE (CMT)
Entity type:Individual
Prefix:
First Name:RANDELLE
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SAN RAFAEL DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5343
Mailing Address - Country:US
Mailing Address - Phone:707-975-2764
Mailing Address - Fax:
Practice Address - Street 1:8099 LA PLAZA
Practice Address - Street 2:SUITE H
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-4253
Practice Address - Country:US
Practice Address - Phone:707-242-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist