Provider Demographics
NPI:1619386307
Name:LOPEZ, JENNIFER SARAH (OMD, DAOM)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SARAH
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OMD, DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15387 SW 150TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2857
Mailing Address - Country:US
Mailing Address - Phone:305-484-5887
Mailing Address - Fax:
Practice Address - Street 1:17150 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3102
Practice Address - Country:US
Practice Address - Phone:305-650-1195
Practice Address - Fax:305-650-1187
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3504208D00000X, 207Q00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty