Provider Demographics
NPI:1902321722
Name:COSTON, JACQULIN
Entity Type:Individual
Prefix:
First Name:JACQULIN
Middle Name:
Last Name:COSTON
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 1:90 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:VA
Mailing Address - Zip Code:24557-2147
Mailing Address - Country:US
Mailing Address - Phone:856-217-1931
Mailing Address - Fax:
Practice Address - Street 1:90 LEWIS RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557-2147
Practice Address - Country:US
Practice Address - Phone:856-217-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver