Provider Demographics
NPI:1548355753
Name:RODRIGUEZ, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-392-7695
Mailing Address - Fax:616-392-6955
Practice Address - Street 1:347 HOOVER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5802
Practice Address - Country:US
Practice Address - Phone:616-392-7695
Practice Address - Fax:616-392-6955
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005181101YM0800X
MI6301009748103TC0700X
MI103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool