Healthcare Provider Details

I. General information

NPI: 1871964585
Provider Name (Legal Business Name): JAN KRUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 WILLIAMS
OXNARD CA
93036-9272
US

IV. Provider business mailing address

11060 HILDRETH CT
SANTA ROSA VALLEY CA
93012-9272
US

V. Phone/Fax

Practice location:
  • Phone: 805-340-1378
  • Fax:
Mailing address:
  • Phone: 805-340-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number122929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: