Provider Demographics
NPI:1043779275
Name:RODESKY, JEREMY SCOTT
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:RODESKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 7TH ST BLDG 700-A78
Mailing Address - Street 2:
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700700-A
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:913-702-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians