Healthcare Provider Details

I. General information

NPI: 1548300379
Provider Name (Legal Business Name): JESSICA LOPEZ PHELPS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E MAIN ST STE 5
BARTOW FL
33830-5065
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 866-234-8534
  • Fax:
Mailing address:
  • Phone: 866-234-8534
  • Fax: 863-837-4469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME174347
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number01059534A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: