Provider Demographics
NPI:1265744379
Name:COSTALES, JENNIFER M (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:COSTALES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LEHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:178 WALDEN WAY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-4105
Mailing Address - Country:US
Mailing Address - Phone:724-992-1917
Mailing Address - Fax:
Practice Address - Street 1:100 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-3364
Practice Address - Country:US
Practice Address - Phone:717-628-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002590152W00000X
PAOEG002338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist