Provider Demographics
NPI:1417544966
Name:RODRIGUEZ, JAN (IMH41870)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:IMH41870
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18495 S DIXIE HWY STE 318
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6817
Mailing Address - Country:US
Mailing Address - Phone:786-258-8499
Mailing Address - Fax:888-318-4788
Practice Address - Street 1:19400 GULFSTREAM RD STE 3123
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8658
Practice Address - Country:US
Practice Address - Phone:786-258-8499
Practice Address - Fax:888-318-4788
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH41870101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health