Provider Demographics
NPI:1356761043
Name:RODRIGUEZ, JESSICA (MS, ATC, CES)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 E VAN BUREN ST
Mailing Address - Street 2:APT 2064
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-3497
Mailing Address - Country:US
Mailing Address - Phone:361-227-0979
Mailing Address - Fax:
Practice Address - Street 1:10215 N 43RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1025
Practice Address - Country:US
Practice Address - Phone:623-810-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10392255A2300X
TX20000064602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer