Provider Demographics
NPI:1891537890
Name:CASTELLANOS, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CASTELLANOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4162 S DAVENCREST LN
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-5368
Mailing Address - Country:US
Mailing Address - Phone:801-859-5950
Mailing Address - Fax:
Practice Address - Street 1:4162 S DAVENCREST LN
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-5368
Practice Address - Country:US
Practice Address - Phone:801-859-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program