Provider Demographics
NPI:1790475283
Name:SORG, JUSTIN JARRELL (RADT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JARRELL
Last Name:SORG
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 WILLOW PASS RD # 313
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2611
Mailing Address - Country:US
Mailing Address - Phone:925-497-0534
Mailing Address - Fax:
Practice Address - Street 1:132 DAMASCUS DR
Practice Address - Street 2:
Practice Address - City:PACHECO
Practice Address - State:CA
Practice Address - Zip Code:94553-2611
Practice Address - Country:US
Practice Address - Phone:925-497-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)