Provider Demographics
NPI:1093230872
Name:LOPEZ, JACEY
Entity Type:Individual
Prefix:
First Name:JACEY
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 1:2525 YOUREE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:318-742-3408
Practice Address - Street 1:1614 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4056
Practice Address - Country:US
Practice Address - Phone:337-369-6600
Practice Address - Fax:337-369-1140
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor