Provider Demographics
NPI:1265277370
Name:LOPES SANTOS, JACQUELINE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LOPES SANTOS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 BROADWAY APT 2
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-2263
Mailing Address - Country:US
Mailing Address - Phone:908-583-7498
Mailing Address - Fax:
Practice Address - Street 1:1214 BROADWAY APT 2
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2263
Practice Address - Country:US
Practice Address - Phone:908-583-7499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor