Provider Demographics
NPI:1417207721
Name:PORTES, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PORTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 CENTRAL PARK AVE
Mailing Address - Street 2:11E
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-2948
Mailing Address - Country:US
Mailing Address - Phone:718-679-4155
Mailing Address - Fax:
Practice Address - Street 1:1853 CENTRAL PARK AVE
Practice Address - Street 2:11E
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-2948
Practice Address - Country:US
Practice Address - Phone:718-679-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY882865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health