Provider Demographics
NPI:1790090470
Name:RODRIGUEZ, JESSICA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:VIGIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1305 SANTA CLARA DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3226
Mailing Address - Country:US
Mailing Address - Phone:505-747-7747
Mailing Address - Fax:
Practice Address - Street 1:BLDG #28 NM 571
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:575-581-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-094921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7606Medicaid