Provider Demographics
NPI:1649740705
Name:RODRIGUEZ, JAYMIE L (DNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:JAYMIE
Middle Name:L
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:JAYMIE
Other - Middle Name:L
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SHEPHERD, SASSER
Mailing Address - Street 1:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-0777
Mailing Address - Country:US
Mailing Address - Phone:877-406-2662
Mailing Address - Fax:
Practice Address - Street 1:304 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MO
Practice Address - Zip Code:65556-7101
Practice Address - Country:US
Practice Address - Phone:877-406-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018040552363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14374335OtherCAQH
MO420064566Medicaid