Provider Demographics
NPI:1205251139
Name:COSTELLO, JENNIFER ANN (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14612 STURTEVANT RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-4455
Mailing Address - Country:US
Mailing Address - Phone:540-290-6889
Mailing Address - Fax:
Practice Address - Street 1:4350 E WEST HWY STE 200
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4426
Practice Address - Country:US
Practice Address - Phone:301-970-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-01
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13932084P0804X
MDH00912572084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry