Provider Demographics
NPI:1902124696
Name:COSTA, JILLIAN JANICE
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:JANICE
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PIGEON RD
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5207
Mailing Address - Country:US
Mailing Address - Phone:781-935-3993
Mailing Address - Fax:
Practice Address - Street 1:157 GREEN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2667
Practice Address - Country:US
Practice Address - Phone:617-983-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health