Provider Demographics
NPI:1114332160
Name:PORCO, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PORCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45068 FOX POINTE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2564
Mailing Address - Country:US
Mailing Address - Phone:734-459-2883
Mailing Address - Fax:
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-849-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206847363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health