Provider Demographics
NPI:1750858858
Name:LOPEZ, JACK (CADCII)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 NE REVERE AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4147
Mailing Address - Country:US
Mailing Address - Phone:541-617-4544
Mailing Address - Fax:541-749-2126
Practice Address - Street 1:155 NE REVERE AVE STE 150
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4147
Practice Address - Country:US
Practice Address - Phone:541-617-4544
Practice Address - Fax:541-749-2126
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-10-11101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)