Provider Demographics
NPI:1992331151
Name:IDICA, JERELYNE DE CASTRO
Entity type:Individual
Prefix:
First Name:JERELYNE
Middle Name:DE CASTRO
Last Name:IDICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 RYAN DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6486
Mailing Address - Country:US
Mailing Address - Phone:973-931-6186
Mailing Address - Fax:
Practice Address - Street 1:7801 POINT MEADOWS DR UNIT 1102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9134
Practice Address - Country:US
Practice Address - Phone:973-931-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT18327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist