Basic Information
| Provider Information | |||||||||
| NPI: | 1598370918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W K ST | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094986016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1105 E FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925434512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514392939 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 109003 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.