Healthcare Provider Details

I. General information

NPI: 1548724909
Provider Name (Legal Business Name): JACQUELINE MARIE PORTELLO RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

841 MAYO CT
BENICIA CA
94510-3803
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone: 707-980-1326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number31868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: