Provider Demographics
NPI:1114709144
Name:PORTORSNOK, JACK PHILIP
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:PHILIP
Last Name:PORTORSNOK
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 1:5320 204TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-5787
Mailing Address - Country:US
Mailing Address - Phone:253-361-5055
Mailing Address - Fax:
Practice Address - Street 1:3680 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5728
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61440913103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst