Provider Demographics
NPI:1497478168
Name:RODARTE, JENNA IRENE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:IRENE
Last Name:RODARTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74143 ENCORE LN
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-2982
Mailing Address - Country:US
Mailing Address - Phone:760-895-9964
Mailing Address - Fax:
Practice Address - Street 1:74143 ENCORE LN
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-2982
Practice Address - Country:US
Practice Address - Phone:760-895-9964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT21-196725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician