Provider Demographics
NPI:1699217109
Name:RODRIGUEZ, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
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 1:900 SE OCEAN BLVD
Mailing Address - Street 2:D130
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2471
Mailing Address - Country:US
Mailing Address - Phone:772-219-7575
Mailing Address - Fax:772-219-9189
Practice Address - Street 1:900 SE OCEAN BLVD
Practice Address - Street 2:D130
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2471
Practice Address - Country:US
Practice Address - Phone:772-219-7575
Practice Address - Fax:772-219-9189
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician