Provider Demographics
NPI:1508128612
Name:RODRIGUEZ, JEANNETTE (MSED-BE)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MSED-BE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8923 210TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2226
Mailing Address - Country:US
Mailing Address - Phone:646-305-6687
Mailing Address - Fax:
Practice Address - Street 1:8923 210TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2226
Practice Address - Country:US
Practice Address - Phone:646-305-6687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50338174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17Medicaid