Provider Demographics
NPI:1427782259
Name:LOPEZ, JACKELINE CORALEE
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:CORALEE
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 1:1041 NE 78TH RD APT 4
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-4215
Mailing Address - Country:US
Mailing Address - Phone:561-669-1539
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 109
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106SOOOOOX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician