Provider Demographics
NPI:1477234383
Name:CRUZ JARQUIN, SAMANTA JISELA
Entity Type:Individual
Prefix:
First Name:SAMANTA
Middle Name:JISELA
Last Name:CRUZ JARQUIN
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 1:3649 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-2019
Mailing Address - Country:US
Mailing Address - Phone:678-992-6530
Mailing Address - Fax:
Practice Address - Street 1:6385 MCGINNIS FERRY ROAD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:470-508-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician