Provider Demographics
NPI:1801219241
Name:KOSTARELLAS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KOSTARELLAS
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 1:19 ONTARIO AVE
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-3719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 ONTARIO AVE
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-3719
Practice Address - Country:US
Practice Address - Phone:978-866-1228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100021225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist