Basic Information
| Provider Information | |||||||||
| NPI: | 1053946731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MIRELLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15928 VENTURA BLVD STE 218 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914364413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185189709 | ||||||||
| FaxNumber: | 7472308320 | ||||||||
| Practice Location | |||||||||
| Address1: | 15928 VENTURA BLVD STE 218 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914364413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185189709 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2020 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.