MEDICARE: JACLYN SOUSA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	021648-1	NY
2	103TC0700X	Clinical Psychologist	10929	MA
3	103TC0700X	Clinical Psychologist	1657	SC

General Provider Information

NPI Number	:	1396197356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN SOUSA PH.D.

Provider Business Mailing Address
First Line	:	308 BERMUDA TOWNE ROW
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-8230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 BERMUDA TOWNE ROW
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-8230
Country	:	US
Telephone Number	:	203-518-1667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2016
Last Update Date	:	10/22/2021

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