Provider Demographics
NPI:1316206600
Name:LOPEZ, JERRY (ASW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4918
Mailing Address - Country:US
Mailing Address - Phone:559-627-2046
Mailing Address - Fax:559-627-9079
Practice Address - Street 1:201 N COURT ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4918
Practice Address - Country:US
Practice Address - Phone:559-627-2046
Practice Address - Fax:559-627-9079
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health