Provider Demographics
NPI:1740211473
Name:DSOUZA, JACQUELINE S (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:S
Last Name:DSOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2651 HILLCREST DRIVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4439
Mailing Address - Country:US
Mailing Address - Phone:715-531-6800
Mailing Address - Fax:715-531-6801
Practice Address - Street 1:2651 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4439
Practice Address - Country:US
Practice Address - Phone:715-531-6800
Practice Address - Fax:715-531-6801
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44846-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34249600Medicaid
WI34249600Medicaid
WIH74488Medicare UPIN