Provider Demographics
NPI:1114445152
Name:LOPEZ, JORDYN (MS, LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:JORDYN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ATLANTIC CHRISTIAN COL DR NE
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2575
Mailing Address - Country:US
Mailing Address - Phone:440-231-7666
Mailing Address - Fax:
Practice Address - Street 1:400 ATLANTIC CHRISTIAN COL DR NE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2505
Practice Address - Country:US
Practice Address - Phone:440-231-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0176569146N00000X
2255A2300X
20000327602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105800774-00Medicaid