Provider Demographics
NPI:1023774536
Name:RODRIGUEZ, JAELENE
Entity type:Individual
Prefix:
First Name:JAELENE
Middle Name:
Last Name:RODRIGUEZ
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 1:274 SOUTH 2ND T
Mailing Address - Street 2:APT 9
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211
Mailing Address - Country:US
Mailing Address - Phone:917-815-0407
Mailing Address - Fax:
Practice Address - Street 1:274 S 2ND ST APT 9
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-5426
Practice Address - Country:US
Practice Address - Phone:917-815-0407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist