Provider Demographics
NPI:1306239330
Name:LOPEZ, JEFFERY THOMAS (MA)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:THOMAS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 NE DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4716
Mailing Address - Country:US
Mailing Address - Phone:503-472-4020
Mailing Address - Fax:
Practice Address - Street 1:617 NE DAVIS ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4716
Practice Address - Country:US
Practice Address - Phone:503-472-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673381Medicaid