Provider Demographics
NPI:1194768622
Name:PORTER, JAYLON J (PT)
Entity type:Individual
Prefix:
First Name:JAYLON
Middle Name:J
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10125 T BURY LANE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708
Mailing Address - Country:US
Mailing Address - Phone:479-857-4212
Mailing Address - Fax:479-857-4212
Practice Address - Street 1:4416 TWIN CITY BLVD
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-5818
Practice Address - Country:US
Practice Address - Phone:254-399-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159238721Medicaid
AR5Y811OtherBCBS
AR5Y811Medicare ID - Type Unspecified