Provider Demographics
NPI:1336877059
Name:LOPEZ, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
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 1:1201 DAME SUSAN LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5777
Mailing Address - Country:US
Mailing Address - Phone:972-740-3150
Mailing Address - Fax:
Practice Address - Street 1:5101 NASH DR
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-1700
Practice Address - Country:US
Practice Address - Phone:469-948-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16772Medicaid