Provider Demographics
NPI:1285286591
Name:PORTER, JORDAN S (DNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:S
Last Name:PORTER
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-3325
Mailing Address - Country:US
Mailing Address - Phone:207-255-4567
Mailing Address - Fax:
Practice Address - Street 1:229 MAIN ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-3606
Practice Address - Country:US
Practice Address - Phone:207-255-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN66553163W00000X
MECNP191169363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1528087004Medicaid