Healthcare Provider Details

I. General information

NPI: 1598370918
Provider Name (Legal Business Name): JESSE DANIEL RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 E FLORIDA AVE
HEMET CA
92543-4512
US

IV. Provider business mailing address

410 W K ST
COLTON CA
92324-3211
US

V. Phone/Fax

Practice location:
  • Phone: 951-439-2939
  • Fax:
Mailing address:
  • Phone: 909-498-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: