Healthcare Provider Details

I. General information

NPI: 1467449827
Provider Name (Legal Business Name): RANDALL W JENNINGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WOODLAND DR
COOS BAY OR
97420-2045
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-2045
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-5151
  • Fax: 541-266-4515
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number43003-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036105293
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberL09261R
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD166994
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: