Provider Demographics
NPI:1023580545
Name:JACKSON-COSTELLO, CARYN LEE
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:LEE
Last Name:JACKSON-COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229H MEDALLION BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708
Mailing Address - Country:US
Mailing Address - Phone:727-412-0569
Mailing Address - Fax:
Practice Address - Street 1:229H MEDALLION BOULEVARD
Practice Address - Street 2:
Practice Address - City:MADEIRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33708
Practice Address - Country:US
Practice Address - Phone:727-412-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant