MEDICARE: JAZMYN LOPEZ M.S

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	235Z00000X	Speech-Language Pathologist	242.005136	IL
2	235Z00000X	Speech-Language Pathologist	146.015002	IL

General Provider Information

NPI Number	:	1740764026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAZMYN LOPEZ M.S

Provider Business Mailing Address
First Line	:	3702 N RICHMOND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3525
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2730
Country	:	US
Telephone Number	:	312-227-6322
Fax Number	:

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

Provider Enumeration Date	:	09/21/2018
Last Update Date	:	08/19/2019

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Directions to “ JAZMYN LOPEZ M.S” Practice Location

Language	Start Address	Practice Location

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