Provider Demographics
NPI:1073072609
Name:CRISTALES, JAYCEE CABALATUNGAN (PT)
Entity Type:Individual
Prefix:
First Name:JAYCEE
Middle Name:CABALATUNGAN
Last Name:CRISTALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 S COUNTRY CLUB RD APT 107
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4486
Mailing Address - Country:US
Mailing Address - Phone:405-328-8673
Mailing Address - Fax:
Practice Address - Street 1:136 S DIPPER LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522-1841
Practice Address - Country:US
Practice Address - Phone:217-428-7767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist