Provider Demographics
NPI:1811206873
Name:LOPEZ, JEANNIEN RENEE (LMP)
Entity Type:Individual
Prefix:
First Name:JEANNIEN
Middle Name:RENEE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NUGENT ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-1542
Mailing Address - Country:US
Mailing Address - Phone:509-910-8016
Mailing Address - Fax:
Practice Address - Street 1:412 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3115
Practice Address - Country:US
Practice Address - Phone:509-469-9974
Practice Address - Fax:509-452-8179
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60176574225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist