Provider Demographics
NPI:1295325702
Name:RANDLE, JENNIE (PTA)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:RANDLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:SPOONHOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2131 S BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-5656
Mailing Address - Country:US
Mailing Address - Phone:920-917-7104
Mailing Address - Fax:
Practice Address - Street 1:2131 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-5656
Practice Address - Country:US
Practice Address - Phone:920-917-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3090225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant