Healthcare Provider Details

I. General information

NPI: 1053557298
Provider Name (Legal Business Name): JENNIFER COSTELLO-SIRI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 SUTPHIN BLVD
JAMAICA NY
11434-1020
US

IV. Provider business mailing address

PO BOX 746087
ATLANTA GA
30374-6087
US

V. Phone/Fax

Practice location:
  • Phone: 187-656-0097
  • Fax: 347-682-4302
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number076568-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number081170
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: