Provider Demographics
NPI:1538609425
Name:KOSTERICH, JORDAN BENJAMIN (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:BENJAMIN
Last Name:KOSTERICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10805-3505
Mailing Address - Country:US
Mailing Address - Phone:914-636-4113
Mailing Address - Fax:914-636-7839
Practice Address - Street 1:5 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10805-3505
Practice Address - Country:US
Practice Address - Phone:914-636-4113
Practice Address - Fax:914-636-7839
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor