Provider Demographics
NPI:1952780082
Name:RODGERS, JESSICA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-5078
Mailing Address - Country:US
Mailing Address - Phone:608-475-0544
Mailing Address - Fax:
Practice Address - Street 1:905 N GURLEY AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-2109
Practice Address - Country:US
Practice Address - Phone:307-686-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1336393834Medicaid