Provider Demographics
NPI:1841845476
Name:RODRIGUEZ, JENNIFER (BCABA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 W 11TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2326 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1808
Practice Address - Country:US
Practice Address - Phone:305-898-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11041106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102878800Medicaid