MEDICARE: JENNIE RODRIGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	LIC-116144	CA

General Provider Information

NPI Number	:	1467270264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE RODRIGUEZ

Provider Business Mailing Address
First Line	:	436 COWELL AVE
Second Line	:
City	:	MANTECA
State	:	CA
Zip	:	95336-5908
Country	:	US
Telephone Number	:	209-403-4216
Fax Number	:

Provider Business Practice Location Address
First Line	:	37 W YOKUTS AVE STE B
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5727
Country	:	US
Telephone Number	:	209-403-4216
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2024
Last Update Date	:	09/30/2024

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Directions to “ JENNIE RODRIGUEZ ” Practice Location

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