Provider Demographics
NPI:1821769373
Name:RODRIGUEZ, JACQUELYN LYZZETTE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LYZZETTE
Last Name:RODRIGUEZ
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 1:3102 CHRISTOPHER ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6011
Mailing Address - Country:US
Mailing Address - Phone:469-628-7528
Mailing Address - Fax:
Practice Address - Street 1:2602 S BELT LINE RD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5344
Practice Address - Country:US
Practice Address - Phone:972-264-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118649235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist