Provider Demographics
NPI:1770720278
Name:SORENSON, JODY MARIE
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MARIE
Last Name:SORENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:SORENSON
Other - Last Name:THEIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12500 NW MILITARY HWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1871
Mailing Address - Country:US
Mailing Address - Phone:210-563-2834
Mailing Address - Fax:
Practice Address - Street 1:12500 NW MILITARY HWY
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78231-1871
Practice Address - Country:US
Practice Address - Phone:210-563-2834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64846101YP2500X
CO2375103T00000X
TX33348103TS0200X
CO0334000103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool