Provider Demographics
NPI:1063658524
Name:DORTILUS, JEAN NERVA (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:NERVA
Last Name:DORTILUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 HILLCREST DR STE 7
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3144
Mailing Address - Country:US
Mailing Address - Phone:254-424-9523
Mailing Address - Fax:
Practice Address - Street 1:3500 HILLCREST DR STE 7
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3144
Practice Address - Country:US
Practice Address - Phone:254-424-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP44382084P0804X, 208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice