Provider Demographics
NPI:1962005843
Name:CRUZ, JESSICA (MAT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 KAMEHAMEHA HWY STE B101
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-2771
Mailing Address - Country:US
Mailing Address - Phone:808-723-2921
Mailing Address - Fax:
Practice Address - Street 1:719 KAMEHAMEHA HWY STE B101
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-2771
Practice Address - Country:US
Practice Address - Phone:808-723-2921
Practice Address - Fax:808-484-9106
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-12032225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI576616Medicaid