Healthcare Provider Details

I. General information

NPI: 1114705753
Provider Name (Legal Business Name): JENNIFER CORTES CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 E VINE ST
KISSIMMEE FL
34744-3733
US

IV. Provider business mailing address

3406 SOHO ST APT 208
ORLANDO FL
32835-7574
US

V. Phone/Fax

Practice location:
  • Phone: 407-847-4152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: