Provider Demographics
NPI:1275720526
Name:COSTIGAN, JENNIFER MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:COSTIGAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:LARKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:18740 W BLUEMOUND ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045
Mailing Address - Country:US
Mailing Address - Phone:262-782-0230
Mailing Address - Fax:
Practice Address - Street 1:18740 W BLUEMOUND ROAD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045
Practice Address - Country:US
Practice Address - Phone:262-782-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3283026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40878700Medicaid