Provider Demographics
NPI:1225875834
Name:LOPEZ, JACKELINE (AGNP- PCP, MSN)
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:AGNP- PCP, MSN
Other - Prefix:
Other - First Name:JACKELINE
Other - Middle Name:
Other - Last Name:ARIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5594 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7648
Mailing Address - Country:US
Mailing Address - Phone:760-217-9258
Mailing Address - Fax:
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:310-825-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95100221163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse