Provider Demographics
NPI:1619506250
Name:COSTELLO, JENNIFER REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41840 ENTERPRISE CIR N
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5654
Mailing Address - Country:US
Mailing Address - Phone:951-225-6400
Mailing Address - Fax:858-633-4697
Practice Address - Street 1:41840 ENTERPRISE CIR N
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5654
Practice Address - Country:US
Practice Address - Phone:951-225-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA841741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical