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General NPI Number Information
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NPI Number | 1306609292
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Entity Type | Organization
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Legal Business Name | JENNIFER NANETTLE RANDOLPH LLC
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Dates
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Enumeration Date | 02/02/2024
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Last Update Date | 02/02/2024
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Provider Practice Location Address
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Address Line | 7715 S COTTAGE GROVE STE, 1 DPT 198502
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City | CHICAGO
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State | IL
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Zip | 60619
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Country | US
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Telephone | 414-304-4881
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Fax |
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Provider Business Mailing Address
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Address Line | 7715 S COTTAGE GROVE STE, 1 DPT 198502
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City | CHICAGO
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State | IL
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Zip | 60619
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Country | US
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Telephone | 414-304-4881
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. JENNIFER NANETTLE RANDOLPH
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Credential | BM
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Telephone | 414-304-4881
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332U00000X
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Taxonomy Name | Home Delivered Meals
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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