Provider Demographics
NPI:1114545449
Name:GODINEZ LOPEZ, JACQUELINE (RD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GODINEZ LOPEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20325 N 51ST AVE STE 166
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4624
Mailing Address - Country:US
Mailing Address - Phone:602-341-5248
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE STE 166
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4624
Practice Address - Country:US
Practice Address - Phone:602-341-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86068218133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ08314495OtherDRIVERS LICENSE