MEDICARE: MR. JESSE DONALD KOSIBA PH.D.

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	103TC0700X	Clinical Psychologist	11743	MA

General Provider Information

NPI Number	:	1760043632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE DONALD KOSIBA PH.D.

Provider Business Mailing Address
First Line	:	1075 WASHINGTON ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02465-2185
Country	:	US
Telephone Number	:	508-876-7202
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 WASHINGTON ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02465-2185
Country	:	US
Telephone Number	:	508-876-7202
Fax Number	:

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

Provider Enumeration Date	:	06/21/2019
Last Update Date	:	02/27/2024

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