Provider Demographics
NPI:1336401173
Name:RODRIGUEZ, JACKELYN
Entity Type:Individual
Prefix:
First Name:JACKELYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKELYN
Other - Middle Name:
Other - Last Name:ALMONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS ED
Mailing Address - Street 1:124 E 176TH ST
Mailing Address - Street 2:APT.4B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-6205
Mailing Address - Country:US
Mailing Address - Phone:646-239-1200
Mailing Address - Fax:
Practice Address - Street 1:124 E 176TH ST
Practice Address - Street 2:APT.4B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6205
Practice Address - Country:US
Practice Address - Phone:646-239-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist