Provider Demographics
NPI:1912408212
Name:RODRIGUEZ, JENIFFER
Entity Type:Individual
Prefix:
First Name:JENIFFER
Middle Name:
Last Name: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:PO BOX 1282
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-5282
Mailing Address - Country:US
Mailing Address - Phone:787-365-7008
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 348 INT KM 0.6 QUEBRADA GRANDE
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-365-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR128461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4582806OtherDRIVER LICENSE