Provider Demographics
NPI:1063450260
Name:RODRIGUEZ, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3649
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8649
Mailing Address - Country:US
Mailing Address - Phone:714-668-2525
Mailing Address - Fax:714-668-2530
Practice Address - Street 1:1190 BAKER ST
Practice Address - Street 2:103
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4108
Practice Address - Country:US
Practice Address - Phone:714-668-2525
Practice Address - Fax:714-668-2530
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics