Provider Demographics
NPI:1588134340
Name:RANDLE, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
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 1:737 W CORNELIA AVE UNIT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2459
Mailing Address - Country:US
Mailing Address - Phone:773-818-5875
Mailing Address - Fax:
Practice Address - Street 1:737 W CORNELIA AVE UNIT G
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2459
Practice Address - Country:US
Practice Address - Phone:773-818-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL33845101YA0400X
IL178.013030101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)