Provider Demographics
NPI:1114602133
Name:RODRIGUEZ, JACKI ELYSE
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:ELYSE
Last Name:RODRIGUEZ
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 1:138 S COLUMBUS AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1337
Mailing Address - Country:US
Mailing Address - Phone:347-398-6993
Mailing Address - Fax:
Practice Address - Street 1:138 S COLUMBUS AVE FL 1
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1337
Practice Address - Country:US
Practice Address - Phone:347-398-6993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health