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 1:15643 LASSELLE ST APT 110
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-4722
Mailing Address - Country:US
Mailing Address - Phone:619-942-0821
Mailing Address - Fax:
Practice Address - Street 1:85 E. RAMONA EXPRESSWAY
Practice Address - Street 2:SUITES 1 - 3
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571
Practice Address - Country:US
Practice Address - Phone:951-349-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA706851041C0700X
CA1074151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical