MEDICARE: JESSICA EMILSSEN CRUZ NINO

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	106S00000X	Behavior Technician	20124975	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922596485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA EMILSSEN CRUZ NINO

Provider Business Mailing Address
First Line	:	4123 VICLIFF RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-8541
Country	:	US
Telephone Number	:	561-401-6844
Fax Number	:

Provider Business Practice Location Address
First Line	:	4123 VICLIFF RD
Second Line	:
City	:	WEST PALM BECH
State	:	FL
Zip	:	33406-6407
Country	:	US
Telephone Number	:	561-401-6844
Fax Number	:

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

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	12/20/2024

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