MEDICARE: DR. JACQUELINE SOUZA MD

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	208000000X	Pediatrics Physician	36110540	IL

General Provider Information

NPI Number	:	1770636979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE SOUZA MD

Provider Business Mailing Address
First Line	:	5215 N CALIFORNIA AVE STE 601
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-8564
Country	:	US
Telephone Number	:	773-878-3627
Fax Number	:	773-989-1669

Provider Business Practice Location Address
First Line	:	5215 N CALIFORNIA AVE STE 601
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-8564
Country	:	US
Telephone Number	:	773-878-3627
Fax Number	:	773-989-1669

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	10/30/2020

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