Provider Demographics
NPI:1598424764
Name:LOPEZ, JANE LIA
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:LIA
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 1:7226 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2003
Mailing Address - Country:US
Mailing Address - Phone:818-235-1414
Mailing Address - Fax:
Practice Address - Street 1:1750 SW SKYLINE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2545
Practice Address - Country:US
Practice Address - Phone:503-894-9630
Practice Address - Fax:833-642-0439
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician