Provider Demographics
NPI:1871339960
Name:PORTILLO POLA, JESSICA JASMIN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JASMIN
Last Name:PORTILLO POLA
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 1:3613 WOODGLEN CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1161
Mailing Address - Country:US
Mailing Address - Phone:702-493-5786
Mailing Address - Fax:
Practice Address - Street 1:6771 W CHARLESTON BLVD STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-9016
Practice Address - Country:US
Practice Address - Phone:702-405-8772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician