Provider Demographics
NPI:1578138442
Name:DACOSTA, JENNA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:MARIE
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5502
Mailing Address - Country:US
Mailing Address - Phone:973-699-6367
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:MEDICAL EDUCATION DEPT FLOOR D7
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102
Practice Address - Country:US
Practice Address - Phone:973-877-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program