Provider Demographics
NPI:1912716192
Name:PORTER, JACE
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7803 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-4435
Mailing Address - Country:US
Mailing Address - Phone:330-968-8563
Mailing Address - Fax:
Practice Address - Street 1:7803 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-4435
Practice Address - Country:US
Practice Address - Phone:330-968-8563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005829175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist