Provider Demographics
NPI:1093175879
Name:SOUSA, JENNIFER (PMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SOUSA
Suffix:
Gender:F
Credentials:PMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 FAY WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-2803
Mailing Address - Country:US
Mailing Address - Phone:508-971-0147
Mailing Address - Fax:
Practice Address - Street 1:30 ROLLING SANDS DRIVE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164
Practice Address - Country:US
Practice Address - Phone:508-971-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA729101YP2500X
FLPMT175106H00000X
CA83546106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional