Provider Demographics
NPI:1396197356
Name:SOUSA, JACLYN (PHD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SOUSA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 BERMUDA TOWNE ROW
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 BERMUDA TOWNE ROW
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8230
Practice Address - Country:US
Practice Address - Phone:203-518-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021648-1103T00000X
MA10929103TC0700X
SC1657103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty