Provider Demographics
NPI:1720588932
Name:SOSOO, JANE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:SOSOO
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 1:5441 S MACADAM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:309-216-7520
Mailing Address - Fax:
Practice Address - Street 1:11740 SW 68TH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9058
Practice Address - Country:US
Practice Address - Phone:309-216-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR10563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health