Provider Demographics
NPI:1225677164
Name:MEJIA LOPEZ, JACQUELINE LISSETTE (SA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LISSETTE
Last Name:MEJIA LOPEZ
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 W 80TH ST APT 224
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-3835
Mailing Address - Country:US
Mailing Address - Phone:786-450-9236
Mailing Address - Fax:
Practice Address - Street 1:2925 W 80TH ST APT 224
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-3835
Practice Address - Country:US
Practice Address - Phone:786-450-9236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19-486246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant