Provider Demographics
NPI:1225329469
Name:CRUZ, JESUS R I (MED; BS)
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:R
Last Name:CRUZ
Suffix:I
Gender:M
Credentials:MED; BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 SW 88TH TER
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-5109
Mailing Address - Country:US
Mailing Address - Phone:954-614-4855
Mailing Address - Fax:
Practice Address - Street 1:5300 SW 88TH TER
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-5109
Practice Address - Country:US
Practice Address - Phone:954-614-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YP2500X
FL1-21-56289103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103218500Medicaid