Provider Demographics
NPI:1558387316
Name:LOPEZ, JEANNETTE MARIE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0098
Mailing Address - Country:US
Mailing Address - Phone:985-727-6055
Mailing Address - Fax:985-727-1627
Practice Address - Street 1:111 CHINCHUBA GDNS
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3261
Practice Address - Country:US
Practice Address - Phone:985-727-6055
Practice Address - Fax:985-727-1627
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10993R2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA65270Medicaid
LA5U832Medicare ID - Type Unspecified
LAF80054Medicare UPIN