MEDICARE: JACKSON DELORD SOUSA LMFT., CSAT-S., CST.

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	106H00000X	Marriage & Family Therapist	MFC 49583	CA

General Provider Information

NPI Number	:	1588092126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON DELORD SOUSA LMFT., CSAT-S., CST.

Provider Business Mailing Address
First Line	:	2660 TOWNSGATE RD STE 520
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-5712
Country	:	US
Telephone Number	:	805-279-2088
Fax Number	:	805-230-2210

Provider Business Practice Location Address
First Line	:	2660 TOWNSGATE RD STE 520
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-5712
Country	:	US
Telephone Number	:	805-279-2088
Fax Number	:	805-230-2210

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

Provider Enumeration Date	:	10/16/2013
Last Update Date	:	08/26/2025

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