Provider Demographics
NPI:1811030273
Name:SOTO, JEANNETTE
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:SOTO
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 1:4907 ROUNDUP RD
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-2434
Mailing Address - Country:US
Mailing Address - Phone:909-433-9300
Mailing Address - Fax:909-433-9308
Practice Address - Street 1:2080 S. E STREET
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-433-9300
Practice Address - Fax:909-433-9308
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35231167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician