Provider Demographics
NPI:1346478526
Name:ROQUE, JODI M (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:M
Last Name:ROQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:MCQUILLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:
Practice Address - Street 1:4417 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1923
Practice Address - Country:US
Practice Address - Phone:773-377-7736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC190472207Q00000X
RILP01622207Q00000X
IL036158109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD13982OtherMEDICAL LICENSE
IL036158109Medicaid