Healthcare Provider Details

I. General information

NPI: 1255900676
Provider Name (Legal Business Name): JENNIFER A LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44199 MONROE ST
INDIO CA
92201-3096
US

IV. Provider business mailing address

12711 BEVERLY BLVD
WHITTIER CA
90601-3005
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8262
  • Fax: 760-770-2240
Mailing address:
  • Phone: 661-528-9855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-MRPKYD
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: