Provider Demographics
NPI:1568420248
Name:OBRIEN, JILL CRUISE (MPT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:CRUISE
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:CRUISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:3111 GUNDERSEN DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8447
Practice Address - Country:US
Practice Address - Phone:608-775-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03660225100000X
WI12216225100000X
MN7995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist