Provider Demographics
NPI:1487393237
Name:SOUSA, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SOUSA
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:PO BOX 2544
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93279-2544
Mailing Address - Country:US
Mailing Address - Phone:559-667-2427
Mailing Address - Fax:559-471-3682
Practice Address - Street 1:1029 N DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4117
Practice Address - Country:US
Practice Address - Phone:559-667-2427
Practice Address - Fax:559-471-3682
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131756390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program