Provider Demographics
NPI:1093774333
Name:COSTA, JESSICA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:COSTA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:MAIERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:136 HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115
Mailing Address - Country:US
Mailing Address - Phone:704-895-6940
Mailing Address - Fax:
Practice Address - Street 1:9800 W KINCEY AV
Practice Address - Street 2:ST 180
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:704-948-2701
Practice Address - Fax:704-948-2859
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4444224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC346606Medicare ID - Type Unspecified