Provider Demographics
NPI:1427264902
Name:RODRIGUEZ, JACQUELYN NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:NICOLE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELYN
Other - Middle Name:NICOLE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11012 E 13 MILE RD, STE # 212
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2572
Mailing Address - Country:US
Mailing Address - Phone:586-582-7150
Mailing Address - Fax:586-582-7164
Practice Address - Street 1:11012 E 13 MILE RD, STE # 212
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2572
Practice Address - Country:US
Practice Address - Phone:586-582-7150
Practice Address - Fax:586-582-7164
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16-0502308-2OtherBCBSM PIN NUMBER
MI16-0502308-2OtherBCBSM PIN NUMBER