Provider Demographics
NPI:1104719053
Name:LOPEZ, JENNIFER (EDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 TORBEN CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9833
Mailing Address - Country:US
Mailing Address - Phone:307-575-9702
Mailing Address - Fax:
Practice Address - Street 1:4215 AVENUE I
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4902
Practice Address - Country:US
Practice Address - Phone:308-635-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool