Healthcare Provider Details

I. General information

NPI: 1669949269
Provider Name (Legal Business Name): JESSICA LOPEZ PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 134 KM 6.9 INT BERROCAL BO BAYANEY
HATILLO PR
00659
US

IV. Provider business mailing address

HC 03 BOX 33806
HATILLO PR
00659
US

V. Phone/Fax

Practice location:
  • Phone: 787-377-3958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5356
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: