Healthcare Provider Details

I. General information

NPI: 1902696461
Provider Name (Legal Business Name): SOMA MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STARE ROAD 570
RANCHOS DE TAOS NM
87557
US

IV. Provider business mailing address

920 STARE ROAD 570
RANCHOS DE TAOS NM
87557
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-4446
  • Fax:
Mailing address:
  • Phone: 575-779-4446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSS JENKINS
Title or Position: CO-OWNER
Credential: LCSW
Phone: 575-779-4446