Healthcare Provider Details

I. General information

NPI: 1588963276
Provider Name (Legal Business Name): JACQUELINE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11428 N 53RD ST
TAMPA FL
33617-2216
US

IV. Provider business mailing address

11428 N 53RD ST
TAMPA FL
33617-2216
US

V. Phone/Fax

Practice location:
  • Phone: 813-374-9416
  • Fax:
Mailing address:
  • Phone: 813-374-9416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: