Provider Demographics
NPI:1417124314
Name:PORTMANN, JENNIFER JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JO
Last Name:PORTMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2026
Mailing Address - Country:US
Mailing Address - Phone:330-364-0894
Mailing Address - Fax:330-602-4812
Practice Address - Street 1:762 S. CLEVELAND-MASSILLON RD.
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333
Practice Address - Country:US
Practice Address - Phone:330-665-4100
Practice Address - Fax:330-665-6748
Is Sole Proprietor?:No
Enumeration Date:2008-05-11
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant