Basic Information
| Provider Information | |||||||||
| NPI: | 1285103119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 26TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941074422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134548623 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2681 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.