Healthcare Provider Details

I. General information

NPI: 1568068013
Provider Name (Legal Business Name): JAEL STEPHANIE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 S SANTA FE AVE STE C
VISTA CA
92083-6910
US

IV. Provider business mailing address

969 S SANTA FE AVE STE C
VISTA CA
92083-6910
US

V. Phone/Fax

Practice location:
  • Phone: 760-315-2615
  • Fax:
Mailing address:
  • Phone: 760-315-2615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: