Provider Demographics
NPI:1457247264
Name:PORTAL, JENNIFER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PORTAL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BERRIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:44 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3718
Mailing Address - Country:US
Mailing Address - Phone:631-804-1955
Mailing Address - Fax:
Practice Address - Street 1:155 E WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1421
Practice Address - Country:US
Practice Address - Phone:631-758-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY785981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse