Healthcare Provider Details

I. General information

NPI: 1306609292
Provider Name (Legal Business Name): JENNIFER NANETTLE RANDOLPH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7715 S COTTAGE GROVE STE, 1 DPT 198502
CHICAGO IL
60619
US

IV. Provider business mailing address

7715 S COTTAGE GROVE STE, 1 DPT 198502
CHICAGO IL
60619
US

V. Phone/Fax

Practice location:
  • Phone: 414-304-4881
  • Fax:
Mailing address:
  • Phone: 414-304-4881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JENNIFER NANETTLE RANDOLPH
Title or Position: MANAGER
Credential: BM
Phone: 414-304-4881