Provider Demographics
NPI:1679561435
Name:CASTELLUCCIO, JENNIFER A (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:CASTELLUCCIO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-690-3460
Practice Address - Fax:425-690-9460
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOA10000132363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016090Medicaid
WAAB11765Medicare ID - Type Unspecified
WA0129149OtherLABOR & INDUSTRIES
WABA4758OtherREGENCE BCBS