Healthcare Provider Details

I. General information

NPI: 1013150416
Provider Name (Legal Business Name): JERAD ALAN SOUZA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-4413
US

IV. Provider business mailing address

1771 HAWKES RD
MCKINLEYVILLE CA
95519-4110
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-2990
  • Fax:
Mailing address:
  • Phone: 805-441-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License NumberPT32451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: