Provider Demographics
NPI:1750684338
Name:RODRIGUEZ-REAL, JENNIFER (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RODRIGUEZ-REAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 VILLA CAPRI CIR APT 202
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-6084
Mailing Address - Country:US
Mailing Address - Phone:787-432-5161
Mailing Address - Fax:
Practice Address - Street 1:1409 VILLA CAPRI CIR APT 202
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-6084
Practice Address - Country:US
Practice Address - Phone:787-432-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR991235Z00000X
FLSZ6103235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist