Provider Demographics
NPI:1942020102
Name:RODRIGUEZ, JESSIE JOSE (PTA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:JOSE
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61216
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1216
Mailing Address - Country:US
Mailing Address - Phone:682-716-0640
Mailing Address - Fax:
Practice Address - Street 1:4100 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76088-8536
Practice Address - Country:US
Practice Address - Phone:682-716-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2059309225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty