Provider Demographics
NPI:1164662961
Name:LOPEZ, JESSIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 JOHN WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3189
Mailing Address - Country:US
Mailing Address - Phone:928-377-1963
Mailing Address - Fax:
Practice Address - Street 1:310 E OAK ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5840
Practice Address - Country:US
Practice Address - Phone:928-377-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013521103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist