1811555436 NPI number — JACOB JESSE ANGLE LOPEZ M.A, CMHC

Table of content: JACOB JESSE ANGLE LOPEZ M.A, CMHC (NPI 1811555436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811555436 NPI number — JACOB JESSE ANGLE LOPEZ M.A, CMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JACOB
Provider Middle Name:
JESSE ANGLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A, CMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811555436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
961 W GREENOAKS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84123-4922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-831-2268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3280 W 3500 S STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST VALLEY CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84119-2668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-209-6997
Provider Business Practice Location Address Fax Number:
801-904-2089
Provider Enumeration Date:
05/29/2019

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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