Provider Demographics
NPI:1013314533
Name:RANDOLPH, JENNIFER LYNN (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W 6TH ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3531
Mailing Address - Country:US
Mailing Address - Phone:310-833-2557
Mailing Address - Fax:424-264-5648
Practice Address - Street 1:1300 W 6TH ST STE 1A
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3531
Practice Address - Country:US
Practice Address - Phone:310-833-2557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16368171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist