Basic Information
| Provider Information | |||||||||
| NPI: | 1760717839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANEL | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1944 S CHANCE AVE | ||||||||
| Address2: | APT. A | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937024510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594439745 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4944 E CLINTON WAY | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592514800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 10/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.