Provider Demographics
NPI:1801446679
Name:PORTILLO, JENNIFER ROSE
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ROSE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:RADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2229 NW IVY CT
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8413
Mailing Address - Country:US
Mailing Address - Phone:760-707-3532
Mailing Address - Fax:
Practice Address - Street 1:116 SE D ST STE A
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1699
Practice Address - Country:US
Practice Address - Phone:541-904-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker