Provider Demographics
NPI:1285341685
Name:BLUE PORTER, JAIMEY
Entity type:Individual
Prefix:
First Name:JAIMEY
Middle Name:
Last Name:BLUE PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 SAINT PATRICKS DR # 224
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5529
Mailing Address - Country:US
Mailing Address - Phone:240-602-3085
Mailing Address - Fax:
Practice Address - Street 1:173 SAINT PATRICKS DR STE 104
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5530
Practice Address - Country:US
Practice Address - Phone:301-818-1206
Practice Address - Fax:301-381-9655
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD201319Y11246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy