MEDICARE: JAQUELINE SOUSA 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	106S00000X	Behavior Technician	RBT-24-367348	FL

General Provider Information

NPI Number	:	1205666112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUELINE SOUSA RODRIGUEZ

Provider Business Mailing Address
First Line	:	6286 SW 10TH TER
Second Line	:
City	:	WEST MIAMI
State	:	FL
Zip	:	33144-4904
Country	:	US
Telephone Number	:	305-939-9595
Fax Number	:

Provider Business Practice Location Address
First Line	:	6286 SW 10TH TER
Second Line	:
City	:	WEST MIAMI
State	:	FL
Zip	:	33144-4904
Country	:	US
Telephone Number	:	305-939-9595
Fax Number	:

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

Provider Enumeration Date	:	08/05/2024
Last Update Date	:	08/05/2024

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