Provider Demographics
NPI:1578807863
Name:RODRIGUEZ, JACQUELYN L (PTA)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:L
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 ORMSBY CIR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3928
Mailing Address - Country:US
Mailing Address - Phone:707-338-7996
Mailing Address - Fax:
Practice Address - Street 1:2440 ORMSBY CIR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3928
Practice Address - Country:US
Practice Address - Phone:707-338-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8493225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant