Provider Demographics
NPI:1568618767
Name:CASTRO, JESSICA (EDS)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:CASTRO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-1300
Mailing Address - Country:US
Mailing Address - Phone:505-866-8333
Mailing Address - Fax:
Practice Address - Street 1:112 MEADOW LAKE RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9449
Practice Address - Country:US
Practice Address - Phone:505-866-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM327656103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool