Provider Demographics
NPI:1295246692
Name:LOPEZ, JACKELINE BEATRIZ (PA-C, RDN)
Entity type:Individual
Prefix:MS
First Name:JACKELINE
Middle Name:BEATRIZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16465 SIERRA LAKES PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86026975133V00000X, 133VN1005X
390200000X
CA62965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program