Provider Demographics
NPI:1134434244
Name:COSTELLO, JESSICA MARIE (MED)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W ANKLAM RD
Mailing Address - Street 2:#111
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W ANKLAM RD
Practice Address - Street 2:#111
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1874
Practice Address - Country:US
Practice Address - Phone:614-716-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator