Provider Demographics
NPI:1598117103
Name:LOPEZ, JACLYNN JEAN
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:JEAN
Last Name:LOPEZ
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 1:2429 NE 10TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-5039
Mailing Address - Country:US
Mailing Address - Phone:405-268-9817
Mailing Address - Fax:
Practice Address - Street 1:2429 NE 10TH ST APT 3
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-5039
Practice Address - Country:US
Practice Address - Phone:405-268-9817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health