Provider Demographics
NPI:1720752512
Name:CASTILLO, JACOBO EZEQUIEL
Entity Type:Individual
Prefix:
First Name:JACOBO
Middle Name:EZEQUIEL
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACOBO
Other - Middle Name:EZEQUIEL
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3001 ROBERT RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-1337
Mailing Address - Country:US
Mailing Address - Phone:561-574-6861
Mailing Address - Fax:
Practice Address - Street 1:1521 FOREST HILL BLVD STE 3B
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6031
Practice Address - Country:US
Practice Address - Phone:561-506-3665
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-169038106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician