Provider Demographics
NPI:1659798205
Name:COSTELLO, JENNIFER (LCSW, RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1005
Mailing Address - Country:US
Mailing Address - Phone:708-831-2122
Mailing Address - Fax:
Practice Address - Street 1:6601 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:708-831-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL68421041C0700X
PACW0185651041C0700X
ORLDD10176233133V00000X
IL1490207731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA261416Medicare UPIN