Provider Demographics
NPI:1063429165
Name:SOUZA, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-1021
Mailing Address - Country:US
Mailing Address - Phone:508-698-0044
Mailing Address - Fax:508-698-5373
Practice Address - Street 1:18 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-1021
Practice Address - Country:US
Practice Address - Phone:508-698-0044
Practice Address - Fax:508-698-5373
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA92334OtherFALLON
MA468086OtherTUFTS
MAAA30839OtherHPHC
MA000000030830OtherBMC HEALTHNET
410399OtherRI BLUE CHIP
MA1611585OtherCIGNA
MAJ25249OtherMABC
MA0165336Medicaid
MAH60240Medicare UPIN
MA0165336Medicaid