Provider Demographics
NPI:1144864679
Name:LOPEZ, JAYMIE (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:JAYMIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4648 GROOM RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7255
Mailing Address - Country:US
Mailing Address - Phone:573-330-7911
Mailing Address - Fax:
Practice Address - Street 1:29101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-9706
Practice Address - Country:US
Practice Address - Phone:909-336-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041070363LF0000X
MO2019040545363LP0808X
CA95021023363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily