Provider Demographics
NPI:1386067924
Name:LOPEZ, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:LOPEZ
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 1:6 QUAY CT
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1631
Mailing Address - Country:US
Mailing Address - Phone:516-554-5440
Mailing Address - Fax:
Practice Address - Street 1:6 QUAY CT
Practice Address - Street 2:
Practice Address - City:CENTERPORT
Practice Address - State:NY
Practice Address - Zip Code:11721-1631
Practice Address - Country:US
Practice Address - Phone:516-554-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist