Provider Demographics
NPI:1811779341
Name:COSTELLO, JESSICA (MS, LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DUBOIS AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08007-1013
Mailing Address - Country:US
Mailing Address - Phone:267-902-4280
Mailing Address - Fax:
Practice Address - Street 1:10000 MIDATLANTIC DR STE 101E
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1504
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012728101YP2500X
NJ37PC00969700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional