Provider Demographics
NPI:1114047495
Name:COSTILLA, JENNIFER L (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1635
Mailing Address - Country:US
Mailing Address - Phone:419-334-7737
Mailing Address - Fax:419-334-2528
Practice Address - Street 1:1823 W STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1635
Practice Address - Country:US
Practice Address - Phone:419-334-7737
Practice Address - Fax:419-334-2528
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12817225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist