Provider Demographics
NPI:1023442647
Name:BRODLEY-LOPEZ, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRODLEY-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 1:5450 GLENRIDGE DRIVE NE
Mailing Address - Street 2:APARTMENT # 3T2
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:912-604-3605
Mailing Address - Fax:
Practice Address - Street 1:5450 GLENRIDGE DR
Practice Address - Street 2:APARTMENT # 3T2
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4969
Practice Address - Country:US
Practice Address - Phone:912-604-3605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist