Provider Demographics
NPI:1598591364
Name:LOPEZ, JACQUELINE A
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
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 1:60 SHAKER RD STE 4
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2760
Mailing Address - Country:US
Mailing Address - Phone:860-394-8203
Mailing Address - Fax:
Practice Address - Street 1:60 SHAKER RD STE 4
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2760
Practice Address - Country:US
Practice Address - Phone:860-394-8203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist