Provider Demographics
NPI:1740827195
Name:LOPEZ, JACK (BCBA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1050 LAKES DR STE 225
Mailing Address - Street 2:PMB #3097
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2910
Mailing Address - Country:US
Mailing Address - Phone:323-943-4400
Mailing Address - Fax:
Practice Address - Street 1:1050 WEST LAKES DR #225
Practice Address - Street 2:PMB #3097
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:323-943-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-63964103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst