Healthcare Provider Details

I. General information

NPI: 1164362000
Provider Name (Legal Business Name): JESUS DANNY MENDIOLA-LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 E TERRACE VIEW DR
SHELTON WA
98584-1828
US

IV. Provider business mailing address

538 E TERRACE VIEW DR
SHELTON WA
98584-1828
US

V. Phone/Fax

Practice location:
  • Phone: 360-490-8067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: