Provider Demographics
NPI:1215434543
Name:PORTOBANCO, JHEANETT
Entity type:Individual
Prefix:
First Name:JHEANETT
Middle Name:
Last Name:PORTOBANCO
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 1:24511 W JAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-9503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24511 W JAYNE AVE
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-9503
Practice Address - Country:US
Practice Address - Phone:559-934-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty