Provider Demographics
NPI:1992307805
Name:LOPEZ, JENNIFER
Entity type:Individual
Prefix:
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 1:3078 STATE ROUTE 43
Mailing Address - Street 2:
Mailing Address - City:MOGADORE
Mailing Address - State:OH
Mailing Address - Zip Code:44260-9773
Mailing Address - Country:US
Mailing Address - Phone:970-314-1357
Mailing Address - Fax:
Practice Address - Street 1:3078 STATE ROUTE 43
Practice Address - Street 2:
Practice Address - City:MOGADORE
Practice Address - State:OH
Practice Address - Zip Code:44260-9773
Practice Address - Country:US
Practice Address - Phone:970-314-1357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage