Healthcare Provider Details

I. General information

NPI: 1144969023
Provider Name (Legal Business Name): JESSICA NICOLE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 LOUISIANA AVE STE A
SAINT CLOUD FL
34769-4116
US

IV. Provider business mailing address

2388 SWEETWATER BLVD
SAINT CLOUD FL
34772-8604
US

V. Phone/Fax

Practice location:
  • Phone: 407-593-0122
  • Fax:
Mailing address:
  • Phone: 407-791-5324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: