Healthcare Provider Details

I. General information

NPI: 1932970878
Provider Name (Legal Business Name): JENNIFER LOPEZ, RD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 SUNFLOWER
PARADISE TX
76073-3219
US

IV. Provider business mailing address

1041 SUNFLOWER
PARADISE TX
76073-3219
US

V. Phone/Fax

Practice location:
  • Phone: 682-554-5708
  • Fax:
Mailing address:
  • Phone: 682-554-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LOPEZ
Title or Position: OWNER
Credential: RDN, LD, CDCES
Phone: 682-554-5708