Provider Demographics
NPI:1295285195
Name:PORTILLO, JASMIN ESMERALDA
Entity type:Individual
Prefix:
First Name:JASMIN
Middle Name:ESMERALDA
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 1:5546 DRAKE ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80504-9761
Mailing Address - Country:US
Mailing Address - Phone:720-771-3095
Mailing Address - Fax:
Practice Address - Street 1:1455 DIXON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8879
Practice Address - Country:US
Practice Address - Phone:720-406-3625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CO099295891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator