Provider Demographics
NPI:1003251935
Name:COSTA, JESSICA MARIE (MSN,CNM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:COSTA
Suffix:
Gender:F
Credentials:MSN,CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-6606
Mailing Address - Country:US
Mailing Address - Phone:330-832-2229
Mailing Address - Fax:
Practice Address - Street 1:123 3RD ST SE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-6606
Practice Address - Country:US
Practice Address - Phone:330-832-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14487-NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife