Provider Demographics
NPI:1851738710
Name:KOSTENBADER, JILL ALLISON (MA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ALLISON
Last Name:KOSTENBADER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078-2580
Mailing Address - Country:US
Mailing Address - Phone:610-389-8870
Mailing Address - Fax:
Practice Address - Street 1:4210 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:SCHNECKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18078-2580
Practice Address - Country:US
Practice Address - Phone:610-389-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 005392-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist