Provider Demographics
NPI:1760043632
Name:KOSIBA, JESSE DONALD (PHD)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:DONALD
Last Name:KOSIBA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2185
Mailing Address - Country:US
Mailing Address - Phone:508-876-7202
Mailing Address - Fax:
Practice Address - Street 1:1075 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2185
Practice Address - Country:US
Practice Address - Phone:508-876-7202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical