Provider Demographics
NPI:1376960377
Name:COSTA, JEANETTE (LMT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:COSTA
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 1:606 DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:07850-1411
Mailing Address - Country:US
Mailing Address - Phone:973-945-8790
Mailing Address - Fax:
Practice Address - Street 1:400 ROUTE 10 WEST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-945-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00073300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist