Healthcare Provider Details

I. General information

NPI: 1992446801
Provider Name (Legal Business Name): JACOB ROBERT SORENSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 WESTLAKE DR
MOUNT AIRY NC
27030-2102
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-719-6100
  • Fax: 336-719-2313
Mailing address:
  • Phone: 336-719-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025-02286
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: