Provider Demographics
NPI:1073264743
Name:LOPEZ, JESSICA CAROLINA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAROLINA
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 1:35 WALNUT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2101
Mailing Address - Country:US
Mailing Address - Phone:781-943-3696
Mailing Address - Fax:
Practice Address - Street 1:35 WALNUT ST STE 200
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2101
Practice Address - Country:US
Practice Address - Phone:781-943-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician