Provider Demographics
NPI:1558863688
Name:COSTA, JAMISSON
Entity type:Individual
Prefix:
First Name:JAMISSON
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-2804
Mailing Address - Country:US
Mailing Address - Phone:310-325-5885
Mailing Address - Fax:310-539-6049
Practice Address - Street 1:2900 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2804
Practice Address - Country:US
Practice Address - Phone:310-325-5885
Practice Address - Fax:310-539-6049
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043656234OtherATHENANET