Provider Demographics
NPI:1285319376
Name:RANDLE, JENNIFER LATRICE
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LATRICE
Last Name:RANDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16W525 MOCKINGBIRD LN APT 203
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6623
Mailing Address - Country:US
Mailing Address - Phone:708-347-1776
Mailing Address - Fax:
Practice Address - Street 1:745 MCCLINTOCK DR STE 100
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0863
Practice Address - Country:US
Practice Address - Phone:708-347-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018697101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health