Provider Demographics
NPI:1275920969
Name:SORIANO, JASON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:SORIANO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3784 FOX POINTE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7078
Mailing Address - Country:US
Mailing Address - Phone:608-215-1110
Mailing Address - Fax:815-395-0671
Practice Address - Street 1:3784 FOX POINTE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-7078
Practice Address - Country:US
Practice Address - Phone:608-215-1110
Practice Address - Fax:815-395-0671
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical