Healthcare Provider Details

I. General information

NPI: 1770295529
Provider Name (Legal Business Name): JELIKAH RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 STEDMAN ST
KETCHIKAN AK
99901-6632
US

IV. Provider business mailing address

721 STEDMAN ST
KETCHIKAN AK
99901-6632
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-7825
  • Fax: 907-225-1541
Mailing address:
  • Phone: 907-225-7825
  • Fax: 907-225-1541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: