Provider Demographics
NPI:1679390090
Name:RODRIGUEZ, JENELL (CDPTCO61563327)
Entity type:Individual
Prefix:
First Name:JENELL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CDPTCO61563327
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 S BROWNE ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2315
Mailing Address - Country:US
Mailing Address - Phone:509-456-5465
Mailing Address - Fax:
Practice Address - Street 1:518 S BROWNE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2315
Practice Address - Country:US
Practice Address - Phone:509-456-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACDPT.CO.61563327101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)