Provider Demographics
NPI:1205196532
Name:RODRIGUEZ, JACK PAUL (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PAUL
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3787 KELLY HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-4522
Mailing Address - Country:US
Mailing Address - Phone:724-258-4966
Mailing Address - Fax:
Practice Address - Street 1:3045 JACKS RUN ROAD
Practice Address - Street 2:CHIROPRACTIC OFFICES-CONSALES HEALTH CENTER
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131
Practice Address - Country:US
Practice Address - Phone:412-678-9123
Practice Address - Fax:412-678-9127
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG004871225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist