Provider Demographics
NPI:1235492737
Name:PORTER, JAKE J III (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:J
Last Name:PORTER
Suffix:III
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:900 CIRCLE 75 PKWY SE STE 1700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3087
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:1240 EAGLES LANDING PKWY STE 300
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5173
Practice Address - Country:US
Practice Address - Phone:770-506-4350
Practice Address - Fax:770-506-9860
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA72625207X00000X
PAMD460968207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery