MEDICARE: JENNIFER PEARSON DE LA CRUZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202011800	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0202011800	OTHER	VA	PHARMACY LICENSE
2	VIRGINIA	OTHER		0202011800

General Provider Information

NPI Number	:	1689276537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER PEARSON DE LA CRUZ

Provider Business Mailing Address
First Line	:	2114 FREDA DR
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22181-3259
Country	:	US
Telephone Number	:	703-517-7167
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 WASHINGTON BLVD
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-4508
Country	:	US
Telephone Number	:	703-351-9220
Fax Number	:	844-411-6504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2020
Last Update Date	:	11/14/2020

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