Provider Demographics
NPI:1679117691
Name:PORTOBANCO, JACQUELINE ANGELES
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANGELES
Last Name:PORTOBANCO
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 1:18713 NW 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2655
Mailing Address - Country:US
Mailing Address - Phone:754-610-0209
Mailing Address - Fax:
Practice Address - Street 1:18713 NW 46TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2655
Practice Address - Country:US
Practice Address - Phone:754-610-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16049224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA16049OtherPERMINENT LICENSURE