Healthcare Provider Details

I. General information

NPI: 1255176343
Provider Name (Legal Business Name): JONATHAN RAMOS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5318 CRENSHAW BLVD
LOS ANGELES CA
90043-1810
US

IV. Provider business mailing address

11669 VALERIO ST APT 125
NORTH HOLLYWOOD CA
91605-3956
US

V. Phone/Fax

Practice location:
  • Phone: 323-293-6291
  • Fax:
Mailing address:
  • Phone: 323-556-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: