=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912857111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKSON CASTRILLO REYES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2026
-----------------------------------------------------
Last Update Date | 02/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2914 NW 24TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-8387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-807-9743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2914 NW 24TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-8387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-807-9743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number | RBT-25-484423
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------