Basic Information
| Provider Information | |||||||||
| NPI: | 1124370960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4317 ASHLAND ST | ||||||||
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| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706054401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
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| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 01/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | ATH.200098 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.