Provider Demographics
NPI:1871027821
Name:PORTELLI TREMONT, JACLYN NICOLE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:PORTELLI TREMONT
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 1:4001 BURNETT WOMACK BUILDING
Mailing Address - Street 2:CB# 7050
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-7050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 BURNETT WOMACK BUILDING
Practice Address - Street 2:CB# 7050
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-7050
Practice Address - Country:US
Practice Address - Phone:919-966-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC227142390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program