Provider Demographics
NPI:1528307204
Name:RUIZ, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RUIZ
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-0187
Mailing Address - Country:US
Mailing Address - Phone:216-659-6669
Mailing Address - Fax:
Practice Address - Street 1:201A WATERFORD ST
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-2226
Practice Address - Country:US
Practice Address - Phone:814-734-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG001698172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist