Provider Demographics
NPI:1235891177
Name:CASTRO, JENNIFER NICHOLE (CADC-I)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICHOLE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 D ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2571
Mailing Address - Country:US
Mailing Address - Phone:925-754-3673
Mailing Address - Fax:925-754-2002
Practice Address - Street 1:1915 D ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2571
Practice Address - Country:US
Practice Address - Phone:925-754-3673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA106S00000X, 172V00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689863516Medicaid