MEDICARE: JENNIFER LOPEZ RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1548190622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LOPEZ RBT

Provider Business Mailing Address
First Line	:	2821 HILLEGAS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3859
Country	:	US
Telephone Number	:	260-338-1241
Fax Number	:	260-338-1241

Provider Business Practice Location Address
First Line	:	9037 STELLHORN CROSSING PKWY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-5860
Country	:	US
Telephone Number	:	260-338-1241
Fax Number	:	260-338-1241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2026
Last Update Date	:	05/21/2026

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Directions to “ JENNIFER LOPEZ RBT” Practice Location

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