Provider Demographics
NPI:1033585021
Name:RODRIGUEZ, JOSE ANTONIO
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANTONIO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANTONIO
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12625 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-0538
Mailing Address - Country:US
Mailing Address - Phone:951-486-7948
Mailing Address - Fax:
Practice Address - Street 1:12625 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-0538
Practice Address - Country:US
Practice Address - Phone:951-486-7948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72189101YM0800X
225400000X, 390200000X
CALCSW940791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program