Basic Information
| Provider Information | |||||||||
| NPI: | 1427105550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTAK | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606797503 | ||||||||
| FaxNumber: | 8606791610 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060306220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606794474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 000312 | CT | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
ID Information
| ID | Type | State | Issuer | Description | 000312 | 01 | CT | CERTIFICATION | OTHER |