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General NPI Number Information
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NPI Number | 1003702705
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Entity Type | Individual
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Provider Name | JEREMY J PORTJE
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Gender | Male
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Dates
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Enumeration Date | 06/17/2025
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 3270 KERNER BLVD STE C
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City | SAN RAFAEL
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State | CA
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Zip | 94901-4840
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Country | US
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Telephone | 415-960-8290
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Fax |
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Provider Business Mailing Address
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Address Line | 55 HILLSIDE TER
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City | NOVATO
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State | CA
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Zip | 94945-3509
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Country | US
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Telephone | 415-960-8290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | MPSS-WIBDCJ
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License Number State | CA
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