Provider Demographics
NPI:1457896664
Name:PORTELL, JASON EDWARD (FNP-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:PORTELL
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7245 RAIDER RD STE C
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3767
Mailing Address - Country:US
Mailing Address - Phone:573-358-4600
Mailing Address - Fax:573-358-4654
Practice Address - Street 1:7245 RAIDER RD STE C
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-3767
Practice Address - Country:US
Practice Address - Phone:573-358-4600
Practice Address - Fax:573-358-4654
Is Sole Proprietor?:No
Enumeration Date:2016-12-23
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily