Provider Demographics
NPI:1205091832
Name:COSTELLO, JENNIFER BETH (LICSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BETH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:BETH
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:11 GLENVIEW ST
Mailing Address - Street 2:
Mailing Address - City:UPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01568-1336
Mailing Address - Country:US
Mailing Address - Phone:774-219-3941
Mailing Address - Fax:
Practice Address - Street 1:11 GLENVIEW ST
Practice Address - Street 2:
Practice Address - City:UPTON
Practice Address - State:MA
Practice Address - Zip Code:01568-1336
Practice Address - Country:US
Practice Address - Phone:774-219-3941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA1168261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health