Healthcare Provider Details

I. General information

NPI: 1861009250
Provider Name (Legal Business Name): JESSI MARIE DE LA CRUZ LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N HIGH ST
LANSING MI
48906-4597
US

IV. Provider business mailing address

1717 N HIGH ST
LANSING MI
48906-4597
US

V. Phone/Fax

Practice location:
  • Phone: 517-372-4700
  • Fax: 517-372-8499
Mailing address:
  • Phone: 517-372-4700
  • Fax: 517-372-8499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP502808
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: