Provider Demographics
NPI:1366623407
Name:LOPEZ-MOORE, JESSICA ANNE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANNE
Last Name:LOPEZ-MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OLD RIVER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9503
Mailing Address - Country:US
Mailing Address - Phone:661-663-4700
Mailing Address - Fax:661-663-4740
Practice Address - Street 1:300 OLD RIVER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9503
Practice Address - Country:US
Practice Address - Phone:661-663-4700
Practice Address - Fax:661-663-4740
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1079471OtherPA-CERTIFICATION