Provider Demographics
NPI:1124021589
Name:KOSSOVE, JILL (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KOSSOVE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:147 COLUMBIA TPKE
Mailing Address - Street 2:STE 308
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-2145
Mailing Address - Country:US
Mailing Address - Phone:201-845-9300
Mailing Address - Fax:201-845-9301
Practice Address - Street 1:10 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-5242
Practice Address - Country:US
Practice Address - Phone:201-291-4040
Practice Address - Fax:201-291-0404
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00125200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ161635466OtherTAX IDENTIFICATION #
NJQ27517Medicare UPIN
NJ084966SHWMedicare ID - Type UnspecifiedMEDICARE ID #