Healthcare Provider Details

I. General information

NPI: 1568420248
Provider Name (Legal Business Name): JILL CRUISE OBRIEN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MARIE CRUISE MPT

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/06/2024
Certification Date: 07/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 STATE RD STE A
LA CROSSE WI
54601-0708
US

IV. Provider business mailing address

3208 STATE RD STE A
LA CROSSE WI
54601-0708
US

V. Phone/Fax

Practice location:
  • Phone: 608-668-6700
  • Fax:
Mailing address:
  • Phone: 608-668-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7995
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12216
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03660
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: