Provider Demographics
NPI:1700309713
Name:VAZQUEZ RODRIGUEZ, JEISEL
Entity Type:Individual
Prefix:
First Name:JEISEL
Middle Name:
Last Name:VAZQUEZ RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SW ABINGDON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2801
Mailing Address - Country:US
Mailing Address - Phone:407-716-8652
Mailing Address - Fax:
Practice Address - Street 1:4181 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3725
Practice Address - Country:US
Practice Address - Phone:772-222-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-19-10418103K00000X
106S00000X
0-19-10418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty