Provider Demographics
NPI:1831425180
Name:RANDALL, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 OLD HOOK ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1368
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:201-634-9647
Practice Address - Street 1:466 OLD HOOK ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1368
Practice Address - Country:US
Practice Address - Phone:201-961-8221
Practice Address - Fax:201-634-9647
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA08874400390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program