Provider Demographics
NPI:1467727081
Name:PORTER, JACOB STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:STEPHEN
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2658
Mailing Address - Country:US
Mailing Address - Phone:951-782-3685
Mailing Address - Fax:
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-782-3685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5426207PP0204X, 208000000X
CA20A15727208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine