Healthcare Provider Details

I. General information

NPI: 1184085136
Provider Name (Legal Business Name): JESSICA S LOPEZ AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 PETRACCA PL
WHITESTONE NY
11357-6000
US

IV. Provider business mailing address

305 E 7TH ST
BROOKLYN NY
11218-3313
US

V. Phone/Fax

Practice location:
  • Phone: 646-722-7610
  • Fax:
Mailing address:
  • Phone: 646-784-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF307662-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: