Provider Demographics
NPI:1336624741
Name:RODRIGUEZ, JEREMY ANTHONY (M ED, BCBA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ANTHONY
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:M ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17515 JUAN CANTU DR
Mailing Address - Street 2:
Mailing Address - City:ELMENDORF
Mailing Address - State:TX
Mailing Address - Zip Code:78112-5522
Mailing Address - Country:US
Mailing Address - Phone:210-789-5905
Mailing Address - Fax:
Practice Address - Street 1:7400 BLANCO RD STE 115
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4361
Practice Address - Country:US
Practice Address - Phone:210-657-7400
Practice Address - Fax:888-977-1704
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2489103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst