Healthcare Provider Details

I. General information

NPI: 1396393898
Provider Name (Legal Business Name): JACQUELINE C RODGERS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 PRINCETON DR SE
ALBUQUERQUE NM
87106-2803
US

IV. Provider business mailing address

507 PRINCETON DR SE
ALBUQUERQUE NM
87106-2803
US

V. Phone/Fax

Practice location:
  • Phone: 318-347-3041
  • Fax:
Mailing address:
  • Phone: 318-347-3041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54967
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: