Healthcare Provider Details

I. General information

NPI: 1639581630
Provider Name (Legal Business Name): JESSICA PORTILLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2014
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 N VIRGIL AVE
LOS ANGELES CA
90004-4811
US

IV. Provider business mailing address

137 N VIRGIL AVE
LOS ANGELES CA
90004-4811
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-1990
  • Fax:
Mailing address:
  • Phone: 323-653-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC175357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: