Provider Demographics
NPI:1588691802
Name:RODRIGUEZ, JENNIFER LYNNE (RD, LD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 SABLE FLS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4870
Mailing Address - Country:US
Mailing Address - Phone:210-896-1464
Mailing Address - Fax:
Practice Address - Street 1:2240 E. WINROW AVE
Practice Address - Street 2:RAYMOND W BLISS ARMY HEALTH CENTER
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06543133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered