Provider Demographics
NPI:1215770078
Name:LOPEZ SANTIAGO, JAQUELINE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:LOPEZ SANTIAGO
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 1:2025 DURANT AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1549
Mailing Address - Country:US
Mailing Address - Phone:424-346-2985
Mailing Address - Fax:
Practice Address - Street 1:2425 BISSO LN STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4886
Practice Address - Country:US
Practice Address - Phone:925-646-5468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program