Basic Information
Provider Information | |||||||||
NPI: | 1679561435 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTELLUCCIO | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3600 LIND AVE SW | ||||||||
Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980574970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256902715 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 26458 MAPLE VALLEY BLACK DIAMOND RD SE | ||||||||
Address2: |   | ||||||||
City: | MAPLE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 98038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256903460 | ||||||||
FaxNumber: | 4256909460 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 08/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | OA10000132 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | OA10000132 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1016090 | 05 | WA |   | MEDICAID |