Healthcare Provider Details

I. General information

NPI: 1205295573
Provider Name (Legal Business Name): JILLIAN RODNEY AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W BELLE AVE
SAINT CHARLES MI
48655-1611
US

IV. Provider business mailing address

611 W BELLE AVE
SAINT CHARLES MI
48655-1611
US

V. Phone/Fax

Practice location:
  • Phone: 989-865-9958
  • Fax: 989-865-8099
Mailing address:
  • Phone: 989-865-9958
  • Fax: 989-865-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2015021434
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: