Healthcare Provider Details

I. General information

NPI: 1164175055
Provider Name (Legal Business Name): JENNIFER ISABEL SOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N GRAND AVE
COVINA CA
91724-2005
US

IV. Provider business mailing address

1444 S HIGHLAND AVE APT H204
FULLERTON CA
92832-3530
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax: 626-859-6537
Mailing address:
  • Phone: 714-574-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number92558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: