Provider Demographics
NPI:1477827590
Name:RODRIGUEZ, JESSICA DAMARIS (MA, MSED)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DAMARIS
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MA, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 CRESCENT ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3218
Mailing Address - Country:US
Mailing Address - Phone:646-221-8211
Mailing Address - Fax:
Practice Address - Street 1:60 MADISON AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1676
Practice Address - Country:US
Practice Address - Phone:212-684-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-06-2670103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst