Provider Demographics
NPI:1568941102
Name:MIXCO-CRUZ, JESSICA CHRISTINA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHRISTINA
Last Name:MIXCO-CRUZ
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 1:32090 POPPY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2510
Mailing Address - Country:US
Mailing Address - Phone:626-665-6065
Mailing Address - Fax:
Practice Address - Street 1:480 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92179-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2022-07-03
Deactivation Date:2018-10-01
Deactivation Code:
Reactivation Date:2018-10-12
Provider Licenses
StateLicense IDTaxonomies
CA1005891041C0700X, 1041C0700X
104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker