Provider Demographics
NPI:1215554506
Name:RODRIGUEZ, JENNICKE GONZALEZ (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:JENNICKE
Middle Name:GONZALEZ
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1467 SE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2183
Mailing Address - Country:US
Mailing Address - Phone:786-351-4138
Mailing Address - Fax:
Practice Address - Street 1:151 NW 11TH ST STE W201
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4361
Practice Address - Country:US
Practice Address - Phone:786-521-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty