Healthcare Provider Details

I. General information

NPI: 1871373951
Provider Name (Legal Business Name): JHONATHAN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S SEMORAN BLVD STE A
ORLANDO FL
32807-1424
US

IV. Provider business mailing address

244 LEE RD
MELBOURNE FL
32904-5135
US

V. Phone/Fax

Practice location:
  • Phone: 407-704-7811
  • Fax: 407-382-0659
Mailing address:
  • Phone: 321-961-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: