Healthcare Provider Details

I. General information

NPI: 1912721069
Provider Name (Legal Business Name): JHOANNA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

6919 N AVERS AVE
LINCOLNWOOD IL
60712-2511
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 773-541-0310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.009096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: