Provider Demographics
NPI:1750096970
Name:RODRIGUEZ, JESUS A
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 E PACHECO BLVD # B168
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4946
Mailing Address - Country:US
Mailing Address - Phone:209-270-0767
Mailing Address - Fax:
Practice Address - Street 1:387 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3153
Practice Address - Country:US
Practice Address - Phone:209-270-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty