MEDICARE: JENNIFER COSTELLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	782080	TX

General Provider Information

NPI Number	:	1538649546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER COSTELLO

Provider Business Mailing Address
First Line	:	5718 SPANISH DAWN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3470
Country	:	US
Telephone Number	:	210-708-7097
Fax Number	:

Provider Business Practice Location Address
First Line	:	5718 SPANISH DAWN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3470
Country	:	US
Telephone Number	:	210-708-7097
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2018
Last Update Date	:	08/19/2018

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Directions to “ JENNIFER COSTELLO ” Practice Location

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