Provider Demographics
NPI:1205632023
Name:CRUZ, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:CRUZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 UNIVERSITY PL # 3579
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3061
Mailing Address - Country:US
Mailing Address - Phone:201-463-5757
Mailing Address - Fax:
Practice Address - Street 1:241 DARDEN DR
Practice Address - Street 2:
Practice Address - City:POQUOSON
Practice Address - State:VA
Practice Address - Zip Code:23662-1215
Practice Address - Country:US
Practice Address - Phone:757-356-2242
Practice Address - Fax:276-242-5657
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-25-412242106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician