Provider Demographics
NPI:1356319628
Name:PORTER, JEANETTA ANN (HOME HEALTH AIDE)
Entity Type:Individual
Prefix:
First Name:JEANETTA
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:HOME HEALTH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 STATE ROUTE 545
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9199
Mailing Address - Country:US
Mailing Address - Phone:419-526-4240
Mailing Address - Fax:
Practice Address - Street 1:2680 STATE ROUTE 545
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9199
Practice Address - Country:US
Practice Address - Phone:419-526-4240
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2101175374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2101175Medicaid