Provider Demographics
NPI:1447844832
Name:LA CRUZ RIVERA, JORGE ANTONIO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
Last Name:LA CRUZ RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3KN18 VIA 66
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-4637
Mailing Address - Country:US
Mailing Address - Phone:787-619-1032
Mailing Address - Fax:
Practice Address - Street 1:3KN18 VIA 66
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983-4637
Practice Address - Country:US
Practice Address - Phone:787-619-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR005472103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling