Provider Demographics
NPI:1871702134
Name:RODOLPH, JENNIFER ELISE (MED)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELISE
Last Name:RODOLPH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6684
Mailing Address - Country:US
Mailing Address - Phone:214-683-0508
Mailing Address - Fax:469-362-2922
Practice Address - Street 1:2591 DALLAS PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-8542
Practice Address - Country:US
Practice Address - Phone:214-683-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional