Provider Demographics
NPI:1144718123
Name:LOPEZ, JAZMIN L (PT)
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:425-430-0710
Mailing Address - Fax:
Practice Address - Street 1:26545 MAPLE VALLEY BLACK DIAMOND RD SE STE K160
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8391
Practice Address - Country:US
Practice Address - Phone:425-578-7211
Practice Address - Fax:425-578-7212
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60835321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist