Provider Demographics
NPI:1497857866
Name:RANDLE, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RANDLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:200 MIFFLIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503
Practice Address - Country:US
Practice Address - Phone:570-342-3145
Practice Address - Fax:570-344-1309
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101631867Medicaid
PA101631867Medicaid
PA097464Medicare ID - Type Unspecified