Provider Demographics
NPI:1003288168
Name:RODRIGUEZ, JACQUELINE (LADC,CAC,APP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LADC,CAC,APP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 SUCCESS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2429
Mailing Address - Country:US
Mailing Address - Phone:203-864-8429
Mailing Address - Fax:
Practice Address - Street 1:243 SUCCESS AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2429
Practice Address - Country:US
Practice Address - Phone:203-864-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CT060669107OtherUBH- CONNECTICARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CTICADC-5511OtherICADC INTERNATIONALLY CERTIFIED ADDICTION COUNSELOR CCB
CTCAC-5511OtherCAC- CERTIFIED ADDICTION COUNSELOR CCB
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CTPENDINGOtherCAQH
CTPENDINGOtherMHN MANAGED HEALTH NETWORK
CT060669107OtherUNITED BEHAVIORAL HEALTH- OPTUM WELLMORE GRP/FACILITY
CT060669107OtherUBH-OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY
CTAPP-5511OtherAPP ASSOCIATE PREVENTION PROFESSIONAL CCB
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CTPENDINGOtherMHN TRICARE NORTH
CTPENDINGMedicaid
CT060669107OtherUBH-OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY