Provider Demographics
NPI:1528773702
Name:RODRIGUEZ, JACQUELINE RAE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RAE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:RAE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:1257 LOWER KULA RD
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-8821
Mailing Address - Country:US
Mailing Address - Phone:808-446-9864
Mailing Address - Fax:
Practice Address - Street 1:200 IKE DR
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9718
Practice Address - Country:US
Practice Address - Phone:808-579-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health