Healthcare Provider Details

I. General information

NPI: 1255961421
Provider Name (Legal Business Name): JENNY LOPEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 02/21/2022
Certification Date: 02/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 91ST ST
JACKSON HEIGHTS NY
11372-7961
US

IV. Provider business mailing address

3708 91ST ST
JACKSON HEIGHTS NY
11372-7961
US

V. Phone/Fax

Practice location:
  • Phone: 718-779-2263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number108415
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: