| Doctor Name: | MR. JERRY WAYNE LOPEZ |
| NPI Number: | 1023155694 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PT |
| License Number: | 22964 |
| Business Practice Address: | 850 E Foothill Blvd Rialto, CA - 923765230 |
| Business Phone Number: | 9094219370 |
| Business Fax Number: | 9094219392 |
| Mailing Address: | 8189 Palmetto Ave Apt 212, FONTANA |
| State: | CA |
| Postal Code: | 923353692 |
| Phone Number: | 9095616473 |
| Fax Number: | 9094219392 |
| NPI Enumeration Date: | 01/31/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 22964 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |