Provider Demographics
NPI:1992972194
Name:GURAM PORTER, JENNIFER NICOLE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:GURAM PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 PRUDENTIAL DR
Mailing Address - Street 2:1506
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8334
Mailing Address - Country:US
Mailing Address - Phone:904-346-0050
Mailing Address - Fax:
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:1506
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-346-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113333207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology