1962889477 NPI number — JENNIFER LYNN PORTER LCSW

Table of content: JENNIFER LYNN PORTER LCSW (NPI 1962889477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962889477 NPI number — JENNIFER LYNN PORTER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962889477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1387
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-1387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-783-1267
Provider Business Mailing Address Fax Number:
844-807-3782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 MCKINLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-783-1267
Provider Business Practice Location Address Fax Number:
844-807-3782
Provider Enumeration Date:
05/04/2015

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: 1041C0700X , with the licence number:  LCSW-43510 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1962889477 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2113084 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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