1205634102 NPI number — MRS. JESSICA RENEE LOPEZ PMHNP

Table of content: MRS. JESSICA RENEE LOPEZ PMHNP (NPI 1205634102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205634102 NPI number — MRS. JESSICA RENEE LOPEZ PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JESSICA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KISER
Provider Other First Name:
JESSICA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205634102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 BERTSCH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESCENT CITY (DEL NORTE COUNTY), CA 955
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-954-7524
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
457 KNOLLCREST DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-954-7524
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  95034174 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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