Provider Demographics
NPI:1225698061
Name:COSTON, JARED DANIEL (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:DANIEL
Last Name:COSTON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 MEMORIAL DR APT 1706
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-5526
Mailing Address - Country:US
Mailing Address - Phone:336-816-0087
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25536363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care