Provider Demographics
NPI:1417124314
Name:PORTMANN, JENNIFER JO (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JO
Last Name:PORTMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:659 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2026
Mailing Address - Country:US
Mailing Address - Phone:330-364-0894
Mailing Address - Fax:330-602-4812
Practice Address - Street 1:3007 TOWN CENTER DR STE 100-101
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-3662
Practice Address - Country:US
Practice Address - Phone:910-354-1281
Practice Address - Fax:910-779-2025
Is Sole Proprietor?:No
Enumeration Date:2008-05-11
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.002761363A00000X
NC0010-12492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant