Individual
DR. JACOB COY COSTELLO
Active
Individual
DR. JACOB COY COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPT
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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