Healthcare Provider Details

I. General information

NPI: 1407091978
Provider Name (Legal Business Name): JANA PORTEUS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 N 7TH ST STE 375
PHOENIX AZ
85006-2754
US

IV. Provider business mailing address

1331 N 7TH ST STE 375
PHOENIX AZ
85006-2754
US

V. Phone/Fax

Practice location:
  • Phone: 602-307-0070
  • Fax: 602-307-0080
Mailing address:
  • Phone: 602-307-0070
  • Fax: 602-307-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number161156
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3644
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4827
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: