Healthcare Provider Details

I. General information

NPI: 1255158366
Provider Name (Legal Business Name): JESSICA CASTRO RODRIGUEZ
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14770 63RD CT N
LOXAHATCHEE FL
33470-4578
US

IV. Provider business mailing address

14770 63RD CT N
LOXAHATCHEE FL
33470-4578
US

V. Phone/Fax

Practice location:
  • Phone: 561-352-7408
  • Fax:
Mailing address:
  • Phone: 561-352-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24375316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: