Provider Demographics
NPI:1114084761
Name:CHERRY, JACQUELINE SUZANNE (PT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:SUZANNE
Last Name:CHERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7515
Mailing Address - Country:US
Mailing Address - Phone:843-856-9523
Mailing Address - Fax:
Practice Address - Street 1:149 SCOTT ST
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7515
Practice Address - Country:US
Practice Address - Phone:843-856-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTHO667Medicaid