Provider Demographics
NPI:1912942046
Name:DE LA CRUZ, JENNIFER SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MOORFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1990 LAKESIDE PKWY
Mailing Address - Street 2:STE 170
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5884
Mailing Address - Country:US
Mailing Address - Phone:770-938-1757
Mailing Address - Fax:770-938-1759
Practice Address - Street 1:2701 N. DECATUR ROAD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-501-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA424463934BMedicaid
GA424463934CMedicaid
CAP54426Medicare UPIN
GA424463934CMedicaid