Provider Demographics
NPI:1275737470
Name:COSTELLO, JACOB COY (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:COY
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8642 F ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-1639
Mailing Address - Country:US
Mailing Address - Phone:402-393-9390
Mailing Address - Fax:402-393-9388
Practice Address - Street 1:825 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2702
Practice Address - Country:US
Practice Address - Phone:402-933-8900
Practice Address - Fax:402-393-9388
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004086225100000X
NE2554335E00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025410100Medicaid
NECK3588OtherRR MEDICARE
NE10025768700Medicaid
NE47082113700Medicaid
NEP00453830OtherMEDICARE RR
NE47082113700Medicaid
NE10025768700Medicaid