Provider Demographics
NPI:1720701568
Name:MADERA SOTO, JONATHAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MADERA SOTO
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:HC 4 BOX 44285
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-9592
Mailing Address - Country:US
Mailing Address - Phone:787-436-1394
Mailing Address - Fax:
Practice Address - Street 1:BO. CIBAO SECTOR FINCA LOS ROBLES
Practice Address - Street 2:CARR. 119 RAMAL 455 K 10.2
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-436-1394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6661103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist