Provider Demographics
NPI:1821630641
Name:RODRIGUEZ, JESSICA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5472 W LOOP 1604 N
Mailing Address - Street 2:SUITE 45 VISTA SALON
Mailing Address - City:SAN ANTONIO TEXAS
Mailing Address - State:TX
Mailing Address - Zip Code:78251
Mailing Address - Country:US
Mailing Address - Phone:860-617-2012
Mailing Address - Fax:
Practice Address - Street 1:5472 W LOOP 1604 N
Practice Address - Street 2:SUITE 45
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:860-617-2012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 246Z00000X
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist