Basic Information
Provider Information | |||||||||
NPI: | 1306270400 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVERA-CRUZ | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: | JUDITH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 664 BROOKS AVE APT 318 | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | CA | ||||||||
PostalCode: | 902913050 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108016199 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 204 HAMPTON DR | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | CA | ||||||||
PostalCode: | 902912623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103966468 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2013 | ||||||||
LastUpdateDate: | 09/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 62099 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LCSW85335 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 101YM0800X | 01 | CA | COUNSELOR MENTAL HEALTH | OTHER |