Provider Demographics
NPI:1053788000
Name:RANDOLPH, JESSICA VERNOLA (DPM)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:VERNOLA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DPM
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Other - Credentials:
Mailing Address - Street 1:6635 W HAPPY VALLEY RD STE A104-276
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2609
Mailing Address - Country:US
Mailing Address - Phone:623-330-0279
Mailing Address - Fax:480-383-6308
Practice Address - Street 1:6677 W THUNDERBIRD RD STE J171
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3703
Practice Address - Country:US
Practice Address - Phone:623-226-5442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZPOD-000891213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist