Healthcare Provider Details

I. General information

NPI: 1568941102
Provider Name (Legal Business Name): JESSICA CHRISTINA MIXCO-CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 07/03/2022
Certification Date: 07/03/2022
Deactivation Date: 10/01/2018
Reactivation Date: 10/12/2018

III. Provider practice location address

480 ALTA RD
SAN DIEGO CA
92179-0001
US

IV. Provider business mailing address

32090 POPPY WAY
LAKE ELSINORE CA
92532-2510
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-6500
  • Fax:
Mailing address:
  • Phone: 626-665-6065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: