Provider Demographics
NPI:1174280770
Name:RODRIGUEZ, JOSE CERECINOS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:CERECINOS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1649
Mailing Address - Country:US
Mailing Address - Phone:520-229-6220
Mailing Address - Fax:
Practice Address - Street 1:3131 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-1649
Practice Address - Country:US
Practice Address - Phone:520-229-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1316229339OtherMENTAL HEALTH PROVIDER