Provider Demographics
NPI:1205290319
Name:ROSALES RODRIGUEZ, JERAMIE LYNN (MD)
Entity type:Individual
Prefix:
First Name:JERAMIE
Middle Name:LYNN
Last Name:ROSALES RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 RAYBURN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1635
Mailing Address - Country:US
Mailing Address - Phone:651-500-4982
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD STE 1250
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1263
Practice Address - Country:US
Practice Address - Phone:314-328-7958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC896352084P0800X
KYR42272084P0800X
MI43015090412084P0800X
390200000X
MO20230488012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100512670Medicaid