Provider Demographics
NPI:1750762027
Name:RODRIGUEZ, JACLYN BERONILLA (DO)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:BERONILLA
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:484-214-6604
Mailing Address - Fax:
Practice Address - Street 1:999 ROUTE 73 N STE 401
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1227
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25MB11321900207QS0010X
NJ25MB11321900207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty