Healthcare Provider Details

I. General information

NPI: 1326693326
Provider Name (Legal Business Name): JACOB BENJAMIN SOLED RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 CHALLENGER WAY
SANTA ROSA CA
95407-5458
US

IV. Provider business mailing address

5554 THOMAS RD
SEBASTOPOL CA
95472-9377
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4900
  • Fax:
Mailing address:
  • Phone: 513-509-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95026966
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number283910
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN95171379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: