=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144896077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JL PSYCH SERVICES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2021
-----------------------------------------------------
Last Update Date | 06/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13168 SW 188TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-812-8815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13168 SW 188TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33177-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-812-8815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON LOPEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-812-8815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------