Healthcare Provider Details

I. General information

NPI: 1992323281
Provider Name (Legal Business Name): JACK RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 W HAMLIN RD STE 101
ROCHESTER HILLS MI
48309-3338
US

IV. Provider business mailing address

1955 W HAMLIN RD STE 101
ROCHESTER HILLS MI
48309-3338
US

V. Phone/Fax

Practice location:
  • Phone: 248-301-6455
  • Fax:
Mailing address:
  • Phone: 586-926-6437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018434
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: