Provider Demographics
NPI:1215161914
Name:SOARES, JENNIFER LYNN
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:SOARES
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 1:2084 E RUSH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-4700
Mailing Address - Country:US
Mailing Address - Phone:209-988-0801
Mailing Address - Fax:
Practice Address - Street 1:2575 E PERRIN AVE STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:209-988-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26060103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist