Provider Demographics
NPI:1033725023
Name:SORENSEN, JADE KIRSTEN
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:KIRSTEN
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S RUTLAND ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3437
Mailing Address - Country:US
Mailing Address - Phone:315-807-8550
Mailing Address - Fax:
Practice Address - Street 1:210 S RUTLAND ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3437
Practice Address - Country:US
Practice Address - Phone:315-807-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010665-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health