Provider Demographics
NPI:1568547313
Name:COSTELLO-ATHERTON-ELY, JACQUELINE JUDETH (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JUDETH
Last Name:COSTELLO-ATHERTON-ELY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:JUDETH
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:516 MOOSIC RD
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-2027
Mailing Address - Country:US
Mailing Address - Phone:570-562-1166
Mailing Address - Fax:570-457-3779
Practice Address - Street 1:516 MOOSIC RD
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-2027
Practice Address - Country:US
Practice Address - Phone:570-562-1166
Practice Address - Fax:570-457-3779
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002586101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015080380002Medicaid