Healthcare Provider Details

I. General information

NPI: 1922576149
Provider Name (Legal Business Name): JACQUELINE CASTILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 CARLISLE BLVD NE STE C-3
ALBUQUERQUE NM
87107-4565
US

IV. Provider business mailing address

4612 HUYANA DR NW
ALBUQUERQUE NM
87120-5597
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-7227
  • Fax:
Mailing address:
  • Phone: 505-358-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0181221
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: