Provider Demographics
NPI:1962889477
Name:PORTER, JENNIFER LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-783-1267
Mailing Address - Fax:844-807-3782
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-435101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1962889477Medicaid
WA2113084Medicaid