Provider Demographics
NPI:1396393898
Name:RODGERS, JACQUELINE C (CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:RODGERS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 PRINCETON DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2803
Mailing Address - Country:US
Mailing Address - Phone:318-347-3041
Mailing Address - Fax:
Practice Address - Street 1:507 PRINCETON DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2803
Practice Address - Country:US
Practice Address - Phone:318-347-3041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54967Medicaid