Provider Demographics
NPI:1760267371
Name:CASTILLO, JESSE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1621
Mailing Address - Country:US
Mailing Address - Phone:208-359-6127
Mailing Address - Fax:208-359-9479
Practice Address - Street 1:217 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1621
Practice Address - Country:US
Practice Address - Phone:208-359-6127
Practice Address - Fax:208-359-9479
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-8804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist