Provider Demographics
NPI:1588651673
Name:PORTU, JESSICA DAYANA (ARNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAYANA
Last Name:PORTU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NW 13TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2305
Mailing Address - Country:US
Mailing Address - Phone:561-955-6400
Mailing Address - Fax:561-955-6614
Practice Address - Street 1:701 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2305
Practice Address - Country:US
Practice Address - Phone:561-955-6400
Practice Address - Fax:561-955-6618
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2857082363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303713400Medicaid
P33979Medicare UPIN
FLY0016YMedicare PIN