Provider Demographics
NPI:1205295573
Name:RODNEY, JILLIAN (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:RODNEY
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MI
Mailing Address - Zip Code:48655-1611
Mailing Address - Country:US
Mailing Address - Phone:989-865-9958
Mailing Address - Fax:989-865-8099
Practice Address - Street 1:611 W BELLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MI
Practice Address - Zip Code:48655-1611
Practice Address - Country:US
Practice Address - Phone:989-865-9958
Practice Address - Fax:989-865-8099
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2015021434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1659326395Medicaid
MI1689022469Medicaid