Provider Demographics
NPI:1366197071
Name:RODRIGUEZ, JERRY JOHNSON (MS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:JOHNSON
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-1719
Mailing Address - Country:US
Mailing Address - Phone:973-868-4927
Mailing Address - Fax:
Practice Address - Street 1:304 JERSEY ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-1719
Practice Address - Country:US
Practice Address - Phone:973-868-4927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer