Provider Demographics
NPI:1992875322
Name:RODRIGUEZ, JORGE (PHD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12359 SUNRISE VALLEY DR
Mailing Address - Street 2:SUITE #220
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3462
Mailing Address - Country:US
Mailing Address - Phone:703-476-9500
Mailing Address - Fax:
Practice Address - Street 1:12359 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE #220
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3462
Practice Address - Country:US
Practice Address - Phone:703-476-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC46810001OtherCF BCBS DC
VA283186OtherAMERIGROUP
VA1230161OtherUHC UBH
VA334206OtherANTHEM
VA1230161OtherUHC UBH
VA283186OtherAMERIGROUP