Provider Demographics
NPI:1073768495
Name:BRU, JORGE JESUS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:JESUS
Last Name:BRU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-4934
Mailing Address - Country:US
Mailing Address - Phone:831-394-4622
Mailing Address - Fax:831-394-1930
Practice Address - Street 1:1178 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-4934
Practice Address - Country:US
Practice Address - Phone:831-394-4622
Practice Address - Fax:831-394-1930
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health