Provider Demographics
NPI:1356579452
Name:COSTELLO, JENNIFER LEE (PHARMD, BCPS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2607
Mailing Address - Country:US
Mailing Address - Phone:973-322-2928
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:973-322-2928
Practice Address - Fax:973-322-5185
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI029044001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist