Provider Demographics
NPI:1548027535
Name:LOPEZ, JEANETTE MARIE (RAC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2702
Mailing Address - Country:US
Mailing Address - Phone:562-450-9495
Mailing Address - Fax:
Practice Address - Street 1:2330 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2220
Practice Address - Country:US
Practice Address - Phone:213-744-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16450101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)