Provider Demographics
NPI:1265892947
Name:REYES-PORTILLO, JAZMIN ALEXANDRA (PHD)
Entity type:Individual
Prefix:DR
First Name:JAZMIN
Middle Name:ALEXANDRA
Last Name:REYES-PORTILLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 51ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1915
Mailing Address - Country:US
Mailing Address - Phone:718-757-4743
Mailing Address - Fax:
Practice Address - Street 1:1051 RIVERSIDE DR
Practice Address - Street 2:UNIT 78
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1007
Practice Address - Country:US
Practice Address - Phone:646-774-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020938-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical