Provider Demographics
NPI:1588092126
Name:SOUSA, JACKSON DELORD (LMFT, CSAT-S, CST)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:DELORD
Last Name:SOUSA
Suffix:
Gender:M
Credentials:LMFT, CSAT-S, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 TOWNSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5866
Mailing Address - Country:US
Mailing Address - Phone:805-308-9800
Mailing Address - Fax:805-267-7191
Practice Address - Street 1:2945 TOWNSGATE RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5866
Practice Address - Country:US
Practice Address - Phone:805-308-9800
Practice Address - Fax:805-267-7191
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 49583106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist