Healthcare Provider Details

I. General information

NPI: 1881241545
Provider Name (Legal Business Name): JASMINE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 COURTLANDT AVE
BRONX NY
10451-5013
US

IV. Provider business mailing address

2180 HOLLAND AVE APT 1N
BRONX NY
10462-1745
US

V. Phone/Fax

Practice location:
  • Phone: 718-485-2100
  • Fax:
Mailing address:
  • Phone: 646-355-7539
  • 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: