Provider Demographics
NPI:1063784320
Name:RODRIGUEZ, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4379 RIDGEWOOD CENTER DR
Mailing Address - Street 2:SUITE 4013
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8322
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:703-680-7953
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR
Practice Address - Street 2:SUITE 4013
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8322
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0078531041C0700X
VA09040090291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical