Individual
DR. JACOB COY COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPT
Contact information
Practice address
825 N 90TH ST, OMAHA, NE 68114-2702
(402) 933-8900
(402) 393-9388
Mailing address
8642 F ST, OMAHA, NE 68127-1639
(402) 393-9390
(402) 393-9388
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
004086
IA
225100000X
Physical Therapist
Primary
2554
NE
335E00000X
Prosthetic/Orthotic Supplier
2554
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10025410100
—
NE
05
—
10025768700
—
NE
05
—
47082113700
—
NE
01
—
CK3588
RR MEDICARE
NE
01
—
P00453830
MEDICARE RR
NE
Enumeration date
06/12/2007
Last updated
06/12/2020
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