Provider Demographics
NPI:1033199054
Name:RODRIQUEZ, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RODRIQUEZ
Suffix:
Gender:M
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:PO BOX 15105
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5105
Mailing Address - Country:US
Mailing Address - Phone:815-654-7772
Mailing Address - Fax:815-654-7009
Practice Address - Street 1:6072 BRYNWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-636-0825
Practice Address - Fax:815-636-2271
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15869Medicare UPIN
IL744760Medicare PIN