Provider Demographics
NPI:1346640646
Name:PORTO, JORDAN (C-T)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PORTO
Suffix:
Gender:F
Credentials:C-T
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:AMBURGY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 MUNSON ST NW STE A
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2981
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:
Practice Address - Street 1:4200 MUNSON ST NW STE A
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2981
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204187-TRNE101Y00000X
OHC.2405889101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor