Provider Demographics
NPI:1730782145
Name:CRUZ, JACQUELINE R
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:R
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 COLUMBIA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6717
Mailing Address - Country:US
Mailing Address - Phone:716-640-4708
Mailing Address - Fax:
Practice Address - Street 1:17 COLUMBIA AVE APT 2
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6717
Practice Address - Country:US
Practice Address - Phone:716-640-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328616164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse