Provider Demographics
NPI:1235821406
Name:CRUZ, GERRYKO R JAKE (LMFT INTERN)
Entity Type:Individual
Prefix:
First Name:GERRYKO
Middle Name:R JAKE
Last Name:CRUZ
Suffix:
Gender:M
Credentials:LMFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 WILLAMETTE STREET, SUITE 301, #140
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4593
Mailing Address - Country:US
Mailing Address - Phone:541-255-1411
Mailing Address - Fax:541-255-1412
Practice Address - Street 1:1599 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4008
Practice Address - Country:US
Practice Address - Phone:541-255-1411
Practice Address - Fax:541-255-1412
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist