Provider Demographics
NPI:1841531134
Name:PORTER, JESSICA ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:PORTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12361 ODELL RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-9489
Mailing Address - Country:US
Mailing Address - Phone:989-239-5878
Mailing Address - Fax:
Practice Address - Street 1:5271 GETWELL RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9608
Practice Address - Country:US
Practice Address - Phone:662-772-5924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015929225100000X
MS6998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPT-6998OtherSTATE LICENSE
MI5501015929OtherSTATE LICENSE