MEDICARE: JENNIFER LOPEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215519426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LOPEZ

Provider Business Mailing Address
First Line	:	670 GOODLETTE-FRANK RD N
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34102-5614
Country	:	US
Telephone Number	:	239-316-7656
Fax Number	:	239-331-2581

Provider Business Practice Location Address
First Line	:	670 GOODLETTE-FRANK RD N
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34102-5614
Country	:	US
Telephone Number	:	239-316-7656
Fax Number	:	239-331-2581

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	04/27/2021

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Directions to “ JENNIFER LOPEZ ” Practice Location

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