Provider Demographics
NPI:1457827529
Name:COSTANZA, JESSICA NICHOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICHOLE
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CLARE RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9612
Mailing Address - Country:US
Mailing Address - Phone:989-329-6874
Mailing Address - Fax:
Practice Address - Street 1:1840 W HOUGHTON LAKE DRIVE
Practice Address - Street 2:UNIT 2
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48629
Practice Address - Country:US
Practice Address - Phone:989-202-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician