Provider Demographics
NPI:1154767903
Name:PORCO, JENNIFER K (NP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:K
Last Name:PORCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEARS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3510
Mailing Address - Country:US
Mailing Address - Phone:201-830-2287
Mailing Address - Fax:201-830-2286
Practice Address - Street 1:1 SEARS DR STE 306
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3510
Practice Address - Country:US
Practice Address - Phone:201-830-2287
Practice Address - Fax:201-830-2286
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00436900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
656665OtherMEDICARE PTAN