Provider Demographics
NPI:1841562733
Name:PORTNOY, PAMELA SUZANNE JACKS (RN, FNP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUZANNE JACKS
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUZANNE
Other - Last Name:JACKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1196 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2421
Mailing Address - Country:US
Mailing Address - Phone:510-558-1391
Mailing Address - Fax:
Practice Address - Street 1:1196 CURTIS ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2421
Practice Address - Country:US
Practice Address - Phone:510-558-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA766010163W00000X
CA21608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse