1255522207 NPI number — JESSICA BOER CASTELO

Table of content: JESSICA BOER CASTELO (NPI 1255522207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255522207 NPI number — JESSICA BOER CASTELO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTELO
Provider First Name:
JESSICA
Provider Middle Name:
BOER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTELO
Provider Other First Name:
MIMI
Provider Other Middle Name:
BOER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255522207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17528
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-0528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-682-3303
Provider Business Mailing Address Fax Number:
405-384-6793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499 E HAMPDEN AVE
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80113-2780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-781-4485
Provider Business Practice Location Address Fax Number:
303-306-7753
Provider Enumeration Date:
08/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  3756 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY.0003756 . This is a "COLORADO MEDICAL LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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