Provider Demographics
NPI:1922548031
Name:JENNIFER RANDOLPH ACUPUNCTURE
Entity Type:Organization
Organization Name:JENNIFER RANDOLPH ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-832-5818
Mailing Address - Street 1:302 W 5TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2738
Mailing Address - Country:US
Mailing Address - Phone:310-832-5818
Mailing Address - Fax:310-832-7236
Practice Address - Street 1:302 W 5TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2738
Practice Address - Country:US
Practice Address - Phone:310-832-5818
Practice Address - Fax:310-832-7236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16368171100000X
CA17194171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty