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General NPI Number Information
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NPI Number | 1275737470
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Entity Type | Individual
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Provider Name | JACOB COY COSTELLO DPT
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Gender | Male
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 06/12/2020
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Provider Practice Location Address
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Address Line | 825 N 90TH ST
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City | OMAHA
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State | NE
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Zip | 68114-2702
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Country | US
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Telephone | 402-933-8900
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Fax | 402-393-9388
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Provider Business Mailing Address
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Address Line | 8642 F ST
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City | OMAHA
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State | NE
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Zip | 68127-1639
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Country | US
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Telephone | 402-393-9390
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Fax | 402-393-9388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 004086
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 2554
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2554
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License Number State | NE
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