Provider Demographics
NPI:1518747922
Name:LOPEZ JAUREGUI, PERLA ADILENE
Entity Type:Individual
Prefix:
First Name:PERLA
Middle Name:ADILENE
Last Name:LOPEZ JAUREGUI
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 1:5534 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419
Mailing Address - Country:US
Mailing Address - Phone:952-855-3578
Mailing Address - Fax:
Practice Address - Street 1:4635 NICOLS RD. #104
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:612-289-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst