Provider Demographics
NPI:1235566340
Name:PORTER, JEVON TRAVELL
Entity Type:Individual
Prefix:
First Name:JEVON
Middle Name:TRAVELL
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 SUMMIT RIDGE DR APT 1030
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-7972
Mailing Address - Country:US
Mailing Address - Phone:702-513-5963
Mailing Address - Fax:
Practice Address - Street 1:1101 W MOANA LN STE 2
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4734
Practice Address - Country:US
Practice Address - Phone:775-337-2394
Practice Address - Fax:775-337-9570
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst