Provider Demographics
NPI:1881100378
Name:RODRIGUEZ, JACOB DANIEL (PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 W THUNDERBIRD RD APT 171
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4928
Mailing Address - Country:US
Mailing Address - Phone:623-293-0707
Mailing Address - Fax:
Practice Address - Street 1:2012 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3151
Practice Address - Country:US
Practice Address - Phone:702-360-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist