MEDICARE: JENNIFER LOPEZ M.A, BCBA, LBA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1447622519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER LOPEZ M.A, BCBA, LBA

Provider Business Mailing Address
First Line	:	5 MANOR DR APT 2A
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-3237
Country	:	US
Telephone Number	:	201-706-1355
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 MANOR DR APT 2A
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-3237
Country	:	US
Telephone Number	:	201-706-1355
Fax Number	:

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

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	08/02/2022

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