Provider Demographics
NPI:1467276295
Name:DE LA CRUZ, JACQUELINE STEPHANIE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:STEPHANIE
Last Name:DE LA CRUZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 NW TREVISO CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9109 S US HIGHWAY 1 STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3453
Practice Address - Country:US
Practice Address - Phone:772-398-1305
Practice Address - Fax:772-398-1307
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1719208D00000X
PR16838-I208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice