=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366381204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER LOPEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2026
-----------------------------------------------------
Last Update Date | 03/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 41ST OCEAN
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-902-7534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 369 110TH STREET OCEAN
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-374-2095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ISW20784
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------