Healthcare Provider Details

I. General information

NPI: 1649909433
Provider Name (Legal Business Name): PRISCILLA JESSICA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N CERRITOS AVE
AZUSA CA
91702-3733
US

IV. Provider business mailing address

3718 SANTIAGO CREEK WAY
ONTARIO CA
91761-0203
US

V. Phone/Fax

Practice location:
  • Phone: 162-681-5340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: