Provider Demographics
NPI:1073174496
Name:LOPEZ, JACKELINE
Entity Type:Individual
Prefix:DR
First Name:JACKELINE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E DIXIE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7601
Mailing Address - Country:US
Mailing Address - Phone:352-326-4031
Mailing Address - Fax:352-360-0257
Practice Address - Street 1:801 E DIXIE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7601
Practice Address - Country:US
Practice Address - Phone:352-326-4031
Practice Address - Fax:352-360-0257
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21359208D00000X
FLACN1303208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109164100Medicaid