Provider Demographics
NPI:1073120549
Name:KOSH, JACQUEAN LYNETTE
Entity Type:Individual
Prefix:
First Name:JACQUEAN
Middle Name:LYNETTE
Last Name:KOSH
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 1:711 HARRY S TRUMAN DR APT 210
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2095
Mailing Address - Country:US
Mailing Address - Phone:301-232-8575
Mailing Address - Fax:
Practice Address - Street 1:711 HARRY S TRUMAN DR APT 210
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-2095
Practice Address - Country:US
Practice Address - Phone:301-232-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional