Provider Demographics
NPI:1619495496
Name:LOPEZ, JOSE JESUS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JESUS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8727 FOREST HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-4026
Mailing Address - Country:US
Mailing Address - Phone:972-754-3980
Mailing Address - Fax:
Practice Address - Street 1:8727 FOREST HILLS BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-4026
Practice Address - Country:US
Practice Address - Phone:972-754-3980
Practice Address - Fax:972-754-3980
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68396103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling