Healthcare Provider Details

I. General information

NPI: 1104318419
Provider Name (Legal Business Name): JENNIFER RODRIGUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25050 SE STARK ST
GRESHAM OR
97030-3327
US

IV. Provider business mailing address

3303 S BOND AVE
PORTLAND OR
97239-4501
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1848
  • Fax:
Mailing address:
  • Phone: 503-494-4373
  • Fax: 503-418-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD210968
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number149570
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD210968
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: