Healthcare Provider Details

I. General information

NPI: 1700629219
Provider Name (Legal Business Name): JESSICA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 F ST
SAN DIEGO CA
92102-2025
US

IV. Provider business mailing address

2404 F ST
SAN DIEGO CA
92102-2025
US

V. Phone/Fax

Practice location:
  • Phone: 619-493-0077
  • Fax:
Mailing address:
  • Phone: 619-493-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: