Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 15015 | CA |
NPI | 1003587304 |
---|---|
Provider Name | Jacklyn De La Cruz |
First Address | Chino Hills, CA 91709-2618 |
Second Address | Riverside, CA 92503-2157 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2021 |
Last Update Date | 27/09/2021 |