Individual
JESSE LOPEZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1 JEFFERSON BARRACKS RD, SAINT LOUIS, MO 63125-4181
(314) 894-6598
Mailing address
123 SHADOWBROOKE, TROY, IL 62294-3625
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5374
MISSOURI ASSOCIATE ALCOHOL DRUG COUNSELOR
MO
Enumeration date
10/11/2022
Last updated
10/11/2022
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