Provider Demographics
NPI:1760110464
Name:DE LA CRUZ, JILLIANNE I (DPT)
Entity Type:Individual
Prefix:
First Name:JILLIANNE
Middle Name:I
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 RIBAUT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5490
Mailing Address - Country:US
Mailing Address - Phone:843-525-0045
Mailing Address - Fax:843-525-0826
Practice Address - Street 1:1076 RIBAUT RD STE 102
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5490
Practice Address - Country:US
Practice Address - Phone:843-525-0045
Practice Address - Fax:843-525-0826
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist