Provider Demographics
NPI:1770636979
Name:SOUZA, JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:SOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 N CALIFORNIA AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-8564
Mailing Address - Country:US
Mailing Address - Phone:773-878-3627
Mailing Address - Fax:773-989-1669
Practice Address - Street 1:5215 N CALIFORNIA AVE STE 601
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-8564
Practice Address - Country:US
Practice Address - Phone:773-878-3627
Practice Address - Fax:773-989-1669
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36110540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics