Provider Demographics
NPI:1972324523
Name:LOPEZ, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JENNIFER LOPEZ
Mailing Address - Street 1:900 VILLAGE SQUARE XING STE 290
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4552
Mailing Address - Country:US
Mailing Address - Phone:239-313-2517
Mailing Address - Fax:
Practice Address - Street 1:603 N FLAMINGO RD STE 350
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1013
Practice Address - Country:US
Practice Address - Phone:954-435-5100
Practice Address - Fax:954-381-8210
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9120056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant