Provider Demographics
NPI:1326815697
Name:DE LA CRUZ MARTIN, JENIFFER MARIA
Entity Type:Individual
Prefix:
First Name:JENIFFER
Middle Name:MARIA
Last Name:DE LA CRUZ MARTIN
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 1:18262 LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3047
Mailing Address - Country:US
Mailing Address - Phone:239-223-7717
Mailing Address - Fax:
Practice Address - Street 1:18262 LOUISE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-3047
Practice Address - Country:US
Practice Address - Phone:239-223-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician