Provider Demographics
NPI:1619628294
Name:LOPEZ, JACOB (PTA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10966 HENDERSON PL
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1830
Mailing Address - Country:US
Mailing Address - Phone:805-795-1311
Mailing Address - Fax:
Practice Address - Street 1:31360 VIA COLINAS STE 104
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-6821
Practice Address - Country:US
Practice Address - Phone:805-492-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50785225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant