Provider Demographics
NPI:1902658677
Name:DE LA CRUZ, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15290 NW 128TH ST
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-7332
Mailing Address - Country:US
Mailing Address - Phone:816-517-2283
Mailing Address - Fax:
Practice Address - Street 1:15290 NW 128TH ST
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-7332
Practice Address - Country:US
Practice Address - Phone:816-517-2283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024003027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily