Provider Demographics
NPI:1760004956
Name:COSTA, JEAN MARIE
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:MARIE
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 GREGG RD APT A
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-1100
Mailing Address - Country:US
Mailing Address - Phone:301-233-0504
Mailing Address - Fax:
Practice Address - Street 1:12041 BOURNEFIELD WAY STE B
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7908
Practice Address - Country:US
Practice Address - Phone:301-592-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist