Provider Demographics
NPI:1992814545
Name:COSTAKES, JESSICA SUE (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUE
Last Name:COSTAKES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUE
Other - Last Name:KECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3572 MARLINSPIKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5871
Mailing Address - Country:US
Mailing Address - Phone:517-214-2713
Mailing Address - Fax:
Practice Address - Street 1:190 SOUTHPARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4120
Practice Address - Country:US
Practice Address - Phone:904-824-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891952600Medicaid
FLPT 22531OtherLICENSE#