Provider Demographics
NPI:1679365613
Name:MOUA, SOR JACOB
Entity type:Individual
Prefix:
First Name:SOR
Middle Name:JACOB
Last Name:MOUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 WARNER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3778
Mailing Address - Country:US
Mailing Address - Phone:530-492-6472
Mailing Address - Fax:
Practice Address - Street 1:1435 WARNER ST APT 1
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3778
Practice Address - Country:US
Practice Address - Phone:530-492-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician