Provider Demographics
NPI:1114772589
Name:LOPEZ, JACQUELINE ALICIA (LCSW, PPS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALICIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N CRESCENT WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5401
Mailing Address - Country:US
Mailing Address - Phone:714-999-7734
Mailing Address - Fax:
Practice Address - Street 1:501 N CRESCENT WAY
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5401
Practice Address - Country:US
Practice Address - Phone:714-999-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical