Provider Demographics
NPI:1053946731
Name:LOPEZ, JESSICA MIRELLA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MIRELLA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15928 VENTURA BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4413
Mailing Address - Country:US
Mailing Address - Phone:818-518-9709
Mailing Address - Fax:747-230-8320
Practice Address - Street 1:15928 VENTURA BLVD STE 218
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4413
Practice Address - Country:US
Practice Address - Phone:818-518-9709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant