Healthcare Provider Details

I. General information

NPI: 1457247264
Provider Name (Legal Business Name): JENNIFER PORTAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BERRIOS RN

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E WOODSIDE AVE
PATCHOGUE NY
11772-1421
US

IV. Provider business mailing address

44 PENNSYLVANIA AVE
MEDFORD NY
11763-3718
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-6565
  • Fax:
Mailing address:
  • Phone: 631-804-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number785981
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number357413
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: