MEDICARE: SOKA PSYCHIATRY AND WELLNESS COMPANY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1245112515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOKA PSYCHIATRY AND WELLNESS COMPANY PC

Provider Business Mailing Address
First Line	:	1508 SPENWICK TER
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-5531
Country	:	US
Telephone Number	:	512-460-0453
Fax Number	:

Provider Business Practice Location Address
First Line	:	1508 SPENWICK TER
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-5531
Country	:	US
Telephone Number	:	512-460-0453
Fax Number	:

Authorized Official
Title or Position	:	PMHNP
Name	:	JEREMIAH ROSS
Credential	:	PMHNP
Telephone Number	:	512-460-0453

Provider Enumeration Date	:	07/25/2025
Last Update Date	:	09/10/2025

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