Provider Demographics
NPI:1932761442
Name:COSTELLO, JESSICA LYN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:COSTELLO
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 1:1513 DEL AMO BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-1635
Mailing Address - Country:US
Mailing Address - Phone:310-318-4355
Mailing Address - Fax:
Practice Address - Street 1:1513 DEL AMO BLVD APT 3
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-1635
Practice Address - Country:US
Practice Address - Phone:310-318-4355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA22-213449106S00000X
CA12474719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician