Provider Demographics
NPI:1053082107
Name:DE LA CRUZ, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-5001
Mailing Address - Country:US
Mailing Address - Phone:559-776-6800
Mailing Address - Fax:
Practice Address - Street 1:4593 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2540
Practice Address - Country:US
Practice Address - Phone:559-222-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121104183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician