Provider Demographics
NPI:1710567110
Name:PORTILLO, JAKE (MD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-702-1244
Mailing Address - Fax:
Practice Address - Street 1:5716 CLEVELAND ST STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1784
Practice Address - Country:US
Practice Address - Phone:757-490-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125080756208100000X
VA0101285892208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program