Healthcare Provider Details

I. General information

NPI: 1467062802
Provider Name (Legal Business Name): JENNIFER LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 E BONITA AVE
POMONA CA
91767-1906
US

IV. Provider business mailing address

11063 WESLEY AVE
MONTCLAIR CA
91763-6092
US

V. Phone/Fax

Practice location:
  • Phone: 909-625-7207
  • Fax:
Mailing address:
  • Phone: 909-247-8982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW110919
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW110919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: