Healthcare Provider Details

I. General information

NPI: 1336067586
Provider Name (Legal Business Name): JENNIFER LOPEZ CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30841 EUCLID AVE STE 103
WILLOUGHBY OH
44094-3100
US

IV. Provider business mailing address

30841 EUCLID AVE STE 103
WILLOUGHBY OH
44094-3100
US

V. Phone/Fax

Practice location:
  • Phone: 216-441-2496
  • Fax: 216-453-5966
Mailing address:
  • Phone: 216-441-2496
  • Fax: 216-453-5966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.195012
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: