Basic Information
| Provider Information | |||||||||
| NPI: | 1467062802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11063 WESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917636092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092478982 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096257207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2020 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ASW110919 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.