MEDICARE: JORGE RENE SOTO LPT

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	167G00000X	Licensed Psychiatric Technician	36461	CA

General Provider Information

NPI Number	:	1376399063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE RENE SOTO LPT

Provider Business Mailing Address
First Line	:	3433 W SHAW AVE STE 108
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3229
Country	:	US
Telephone Number	:	559-558-4051
Fax Number	:

Provider Business Practice Location Address
First Line	:	3115 N MILLBROOK AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93703-1425
Country	:	US
Telephone Number	:	559-600-2382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	05/13/2026

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Directions to “ JORGE RENE SOTO LPT” Practice Location

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