Healthcare Provider Details

I. General information

NPI: 1376399063
Provider Name (Legal Business Name): JORGE RENE SOTO LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JORGE RENE ZAVALA

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 N MILLBROOK AVE
FRESNO CA
93703-1425
US

IV. Provider business mailing address

3433 W SHAW AVE STE 108
FRESNO CA
93711-3229
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-2382
  • Fax:
Mailing address:
  • Phone: 559-558-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: