Provider Demographics
NPI:1518498542
Name:RODGERS, JACQUELYN MICHELLE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:RODGERS
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 1:2474 TULANE ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2434
Mailing Address - Country:US
Mailing Address - Phone:541-992-6100
Mailing Address - Fax:
Practice Address - Street 1:2474 TULANE ST
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-2434
Practice Address - Country:US
Practice Address - Phone:541-992-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14551782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer