Provider Demographics
NPI:1104134709
Name:COSTA MCCUTCHEON, JEAN M
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:COSTA MCCUTCHEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 WESTERN WAY
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-4506
Mailing Address - Country:US
Mailing Address - Phone:781-934-2444
Mailing Address - Fax:
Practice Address - Street 1:39A INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4868
Practice Address - Country:US
Practice Address - Phone:508-830-1444
Practice Address - Fax:508-830-3655
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health