Provider Demographics
NPI:1639506637
Name:LOPEZ, JACQUELINE (MA, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 34TH AVE NE STE L
Mailing Address - Street 2:
Mailing Address - City:QUIL CEDA VILLAGE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8085
Mailing Address - Country:US
Mailing Address - Phone:360-965-0751
Mailing Address - Fax:
Practice Address - Street 1:4220 80TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3423
Practice Address - Country:US
Practice Address - Phone:360-657-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003404235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist