Provider Demographics
NPI:1316641186
Name:ROSALES RODRIGUEZ, JACINTO ENRIQUE
Entity type:Individual
Prefix:
First Name:JACINTO
Middle Name:ENRIQUE
Last Name:ROSALES 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 1:1610 SW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-3420
Mailing Address - Country:US
Mailing Address - Phone:786-255-8155
Mailing Address - Fax:
Practice Address - Street 1:1610 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-3420
Practice Address - Country:US
Practice Address - Phone:786-255-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-263886106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician