Provider Demographics
NPI:1578810875
Name:KOSTELNIK, JESSICA O (PHD, LCP)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:O
Last Name:KOSTELNIK
Suffix:
Gender:F
Credentials:PHD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:205 EAST HIGH STREET
Mailing Address - Street 2:JAO5J@VIRGINIA.EDU
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902
Mailing Address - Country:US
Mailing Address - Phone:434-963-0324
Mailing Address - Fax:434-971-4525
Practice Address - Street 1:205 E HIGH ST
Practice Address - Street 2:JAO5J@VIRGINIA.EDU
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5516
Practice Address - Country:US
Practice Address - Phone:434-963-0324
Practice Address - Fax:434-971-4525
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical