Provider Demographics
NPI:1417788936
Name:LOPEZ, JASMINE ROSALYN
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:ROSALYN
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 1:402 CHICAGO WOODS CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-9325
Mailing Address - Country:US
Mailing Address - Phone:321-318-0702
Mailing Address - Fax:
Practice Address - Street 1:102 PARK PLACE BLVD STE C
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2358
Practice Address - Country:US
Practice Address - Phone:407-385-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-368194106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician