Healthcare Provider Details

I. General information

NPI: 1710184940
Provider Name (Legal Business Name): JENNIFER ANN CRUZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN BOWMAN PA-C

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BELLEFONTAINE AVE FL 7
LIMA OH
45804-2800
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 419-998-4496
  • Fax: 419-998-4463
Mailing address:
  • Phone: 419-998-4575
  • Fax: 419-998-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9105529
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.004138
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: