Provider Demographics
NPI:1003926098
Name:PORTER, JESSICA BROOKE (BS, FAODP)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:BROOKE
Last Name:PORTER
Suffix:
Gender:F
Credentials:BS, FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 IRONWOOD CT
Mailing Address - Street 2:APT 004
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1261
Mailing Address - Country:US
Mailing Address - Phone:248-909-0189
Mailing Address - Fax:
Practice Address - Street 1:1435 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1549
Practice Address - Country:US
Practice Address - Phone:248-666-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)