1003926098 NPI number — MISS JESSICA BROOKE PORTER B.S, FAODP

Table of content: MISS JESSICA BROOKE PORTER B.S, FAODP (NPI 1003926098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003926098 NPI number — MISS JESSICA BROOKE PORTER B.S, FAODP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
JESSICA
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
B.S, FAODP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003926098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1147 IRONWOOD CT
Provider Second Line Business Mailing Address:
APT 004
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48307-1261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-909-0189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1435 N OAKLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48327-1549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-666-2720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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