Provider Demographics
NPI:1255522207
Name:CASTELO, JESSICA BOER
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BOER
Last Name:CASTELO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:BOER
Other - Last Name:CASTELO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 17528
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0528
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-384-6793
Practice Address - Street 1:499 E HAMPDEN AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2780
Practice Address - Country:US
Practice Address - Phone:303-781-4485
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3756103G00000X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPSY.0003756OtherCOLORADO MEDICAL LICENSE