Healthcare Provider Details

I. General information

NPI: 1376053082
Provider Name (Legal Business Name): JERSLIN DE SOUSA DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2017
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 EASTERN PKWY
BROOKLYN NY
11233-4804
US

IV. Provider business mailing address

1650 EASTERN PKWY
BROOKLYN NY
11233-4804
US

V. Phone/Fax

Practice location:
  • Phone: 646-588-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX012739-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberX0121739-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: