Provider Demographics
NPI:1497377493
Name:LOPEZ, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13039 CRANSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3408
Mailing Address - Country:US
Mailing Address - Phone:818-438-1483
Mailing Address - Fax:
Practice Address - Street 1:15099 MISSION HILLS RD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1102
Practice Address - Country:US
Practice Address - Phone:818-837-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA10479208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation