Provider Demographics
NPI:1801280417
Name:DECOSTOLE, JESSICA (MS, RDN, LDN, CDE)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:DECOSTOLE
Suffix:
Gender:F
Credentials:MS, RDN, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 S ELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3949
Mailing Address - Country:US
Mailing Address - Phone:347-992-4041
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:GOOD HEALTH CENTER 2ND FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21238
Practice Address - Country:US
Practice Address - Phone:443-444-4912
Practice Address - Fax:443-444-4884
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3562133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDX3562OtherTHE BOARD OF DIETETIC PRACTICE OF THE STATE OF MARYLAND