Provider Demographics
NPI:1447287768
Name:CASTELLANO, JESSICA (OWNER)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:CASTELLANO
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 SE 20 ROAD
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035
Mailing Address - Country:US
Mailing Address - Phone:305-230-6620
Mailing Address - Fax:305-230-6620
Practice Address - Street 1:121 SOUTH STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317
Practice Address - Country:US
Practice Address - Phone:954-792-7113
Practice Address - Fax:954-792-7396
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor