Provider Demographics
NPI:1124379722
Name:PORSCH, JAKE R (PT)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:R
Last Name:PORSCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 FOREST LN STE 180
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-7939
Mailing Address - Country:US
Mailing Address - Phone:972-494-1419
Mailing Address - Fax:972-494-2069
Practice Address - Street 1:2046 FOREST LN STE 180
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-7939
Practice Address - Country:US
Practice Address - Phone:972-494-1419
Practice Address - Fax:972-494-2069
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1218719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist