Healthcare Provider Details

I. General information

NPI: 1720902042
Provider Name (Legal Business Name): JESSICA IVETTE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 S SHERRILL ST
ANAHEIM CA
92804-4022
US

IV. Provider business mailing address

833 S SHERRILL ST
ANAHEIM CA
92804-4022
US

V. Phone/Fax

Practice location:
  • Phone: 310-916-4222
  • Fax:
Mailing address:
  • Phone: 310-916-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: