Provider Demographics
NPI:1275119885
Name:LOPEZ, JEANNETTE
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name: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 1:1051 S WOOSTER ST APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13001 RAMONA BLVD STE E
Practice Address - Street 2:
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-3752
Practice Address - Country:US
Practice Address - Phone:310-869-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist