Provider Demographics
NPI:1295227155
Name:PORTILLOS, JESSICA DENISSE (DNP-CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DENISSE
Last Name:PORTILLOS
Suffix:
Gender:F
Credentials:DNP-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 S PARKCREST ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-9517
Mailing Address - Country:US
Mailing Address - Phone:480-385-8521
Mailing Address - Fax:
Practice Address - Street 1:1800 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3742
Practice Address - Country:US
Practice Address - Phone:602-251-8359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA1524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered