Healthcare Provider Details

I. General information

NPI: 1205290319
Provider Name (Legal Business Name): JERAMIE LYNN ROSALES RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 1250
RICHMOND HEIGHTS MO
63117-1263
US

IV. Provider business mailing address

625 RAYBURN AVE
SAINT LOUIS MO
63126-1635
US

V. Phone/Fax

Practice location:
  • Phone: 314-328-7958
  • Fax:
Mailing address:
  • Phone: 651-500-4982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number89635
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR4227
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301509041
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023048801
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: