Basic Information
| Provider Information | |||||||||
| NPI: | 1063429165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUZA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | FOXBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020351021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086980044 | ||||||||
| FaxNumber: | 5086985373 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | FOXBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020351021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086980044 | ||||||||
| FaxNumber: | 5086985373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 209230 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 92334 | 01 | MA | FALLON | OTHER | 468086 | 01 | MA | TUFTS | OTHER | AA30839 | 01 | MA | HPHC | OTHER | 000000030830 | 01 | MA | BMC HEALTHNET | OTHER | 410399 | 01 | RI BLUE CHIP | OTHER | 1611585 | 01 | MA | CIGNA | OTHER | J25249 | 01 | MA | MABC | OTHER | 0165336 | 05 | MA | MEDICAID |