Healthcare Provider Details

I. General information

NPI: 1609523398
Provider Name (Legal Business Name): JEANILY CRUZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST STE 425
BALTIMORE MD
21211-2135
US

IV. Provider business mailing address

711 W 40TH ST STE 425
BALTIMORE MD
21211-2135
US

V. Phone/Fax

Practice location:
  • Phone: 617-680-5262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26933
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904019718
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: