Provider Demographics
NPI:1821499948
Name:LOPEZ, JOSE LUIS JR
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:LOPEZ
Suffix:JR
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 1:1182 W BLAINE ST
Mailing Address - Street 2:APT 4
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7656
Mailing Address - Country:US
Mailing Address - Phone:619-942-0821
Mailing Address - Fax:951-242-7733
Practice Address - Street 1:12968 FREDERICK ST STE D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5229
Practice Address - Country:US
Practice Address - Phone:951-242-7738
Practice Address - Fax:951-242-7733
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA706851041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health