Provider Demographics
NPI:1740773480
Name:CROSS, JENNIFER LYNN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:CROSS
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 1:508 HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3835
Mailing Address - Country:US
Mailing Address - Phone:805-752-1112
Mailing Address - Fax:805-594-1460
Practice Address - Street 1:508 HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3835
Practice Address - Country:US
Practice Address - Phone:805-752-1112
Practice Address - Fax:805-594-1460
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA776063163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1528150711OtherOUTPATIENT EATING DISORDER TREATMENT PROGRAM