Healthcare Provider Details

I. General information

NPI: 1912857111
Provider Name (Legal Business Name): JACKSON MANUEL CASTRILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2914 NW 24TH AVE
CAPE CORAL FL
33993-8387
US

IV. Provider business mailing address

2914 NW 24TH AVE
CAPE CORAL FL
33993-8387
US

V. Phone/Fax

Practice location:
  • Phone: 305-807-9743
  • Fax:
Mailing address:
  • Phone: 305-807-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-484423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: