Provider Demographics
NPI:1942938154
Name:PORTILLO, JAZMIN CLAUDIA
Entity Type:Individual
Prefix:
First Name:JAZMIN
Middle Name:CLAUDIA
Last Name:PORTILLO
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 1:3611 85TH ST NW TRLR 86
Mailing Address - Street 2:
Mailing Address - City:ORONOCO
Mailing Address - State:MN
Mailing Address - Zip Code:55960-9609
Mailing Address - Country:US
Mailing Address - Phone:507-219-0205
Mailing Address - Fax:
Practice Address - Street 1:3253 19TH ST NW STE 1
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6794
Practice Address - Country:US
Practice Address - Phone:507-218-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health