Healthcare Provider Details

I. General information

NPI: 1538049747
Provider Name (Legal Business Name): JESSICA DE LA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 82ND DR
GLADSTONE OR
97027-1803
US

IV. Provider business mailing address

880 82ND DR
GLADSTONE OR
97027-1803
US

V. Phone/Fax

Practice location:
  • Phone: 971-378-0367
  • Fax: 503-974-9679
Mailing address:
  • Phone: 971-378-0367
  • Fax: 503-974-9679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: