Provider Demographics
NPI:1558439398
Name:SOUSA, JASON ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALLEN
Last Name:SOUSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 TOLLAND TURNPIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANCHESTER
Mailing Address - State:CO
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-432-7432
Mailing Address - Fax:860-432-9049
Practice Address - Street 1:1127 TOLLAND TURNPIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:MANCHESTER
Practice Address - State:CO
Practice Address - Zip Code:06042
Practice Address - Country:US
Practice Address - Phone:860-432-7432
Practice Address - Fax:860-432-9049
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1692111N00000X
CT001722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03898OtherGROUP MEDICARE
MECR1692OtherLICENSE