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General NPI Number Information
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NPI Number | 1992814545
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Entity Type | Individual
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Provider Name | JESSICA SUE COSTAKES PT
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Gender | Female
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 10/07/2008
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Provider Practice Location Address
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Address Line | 190 SOUTHPARK BLVD SUITE 100
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-4120
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Country | US
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Telephone | 904-824-1478
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Fax |
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Provider Business Mailing Address
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Address Line | 3572 MARLINSPIKE DR
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City | TAMPA
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State | FL
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Zip | 33607-5871
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Country | US
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Telephone | 517-214-2713
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Fax |
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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 |
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License Number State |
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