Healthcare Provider Details

I. General information

NPI: 1942998760
Provider Name (Legal Business Name): JESSICA LOPEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NORTHWEST DR
PLAINVILLE CT
06062-1552
US

IV. Provider business mailing address

35 RUTH ST APT 46
BRISTOL CT
06010-3218
US

V. Phone/Fax

Practice location:
  • Phone: 203-232-4051
  • Fax:
Mailing address:
  • Phone: 787-201-3793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12415
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: