Provider Demographics
NPI:1063665529
Name:DE COSTA, JENNIFER L (PHD, MFT, CSAC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:DE COSTA
Suffix:
Gender:F
Credentials:PHD, MFT, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5751 KUAKINI HWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1752
Mailing Address - Country:US
Mailing Address - Phone:808-326-5629
Mailing Address - Fax:808-329-5057
Practice Address - Street 1:75-5751 KUAKINI HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1752
Practice Address - Country:US
Practice Address - Phone:808-326-5629
Practice Address - Fax:808-329-5057
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT272106H00000X
HI1249-05101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1249-05OtherCSAC
HIMFT272OtherMFT