Provider Demographics
NPI:1821624214
Name:CASTELLO, JESSICA NICOLE (CMS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:CASTELLO
Suffix:
Gender:F
Credentials:CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45015-1653
Mailing Address - Country:US
Mailing Address - Phone:513-892-4673
Mailing Address - Fax:513-737-1107
Practice Address - Street 1:36 N DETROIT ST STE 105
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2963
Practice Address - Country:US
Practice Address - Phone:937-610-4673
Practice Address - Fax:937-736-2615
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
OHAPS.001633175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490421Medicaid