Provider Demographics
NPI:1407005200
Name:PORTER, JEREMY DEAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DEAN
Last Name:PORTER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 W INDIANA ST
Mailing Address - Street 2:#1
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1509
Mailing Address - Country:US
Mailing Address - Phone:360-224-8845
Mailing Address - Fax:
Practice Address - Street 1:1486 ELECTRIC AVE
Practice Address - Street 2:SUITE #103
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-2410
Practice Address - Country:US
Practice Address - Phone:360-671-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013632174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist