Healthcare Provider Details

I. General information

NPI: 1922250513
Provider Name (Legal Business Name): JESSICA L. CRUZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 E MAIN STE F
PUYALLUP WA
98372-3170
US

IV. Provider business mailing address

1416 E MAIN STE F
PUYALLUP WA
98372-3170
US

V. Phone/Fax

Practice location:
  • Phone: 253-445-8663
  • Fax:
Mailing address:
  • Phone: 253-445-8663
  • Fax: 253-445-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: