Provider Demographics
NPI:1972159580
Name:SAN MIGUEL RODRIGUEZ, JAIME
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:SAN MIGUEL 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 1:360 W 39TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4340
Mailing Address - Country:US
Mailing Address - Phone:786-804-1000
Mailing Address - Fax:
Practice Address - Street 1:360 W 39TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4340
Practice Address - Country:US
Practice Address - Phone:786-804-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2023-08-24
Deactivation Date:2019-08-12
Deactivation Code:
Reactivation Date:2019-08-21
Provider Licenses
StateLicense IDTaxonomies
FL1-14-16970103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty