Provider Demographics
NPI:1487225686
Name:PORTER, JAMAL JR (NP)
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 WILLIAMSON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6863
Mailing Address - Country:US
Mailing Address - Phone:704-981-0044
Mailing Address - Fax:
Practice Address - Street 1:249 WILLIAMSON RD STE 101
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6863
Practice Address - Country:US
Practice Address - Phone:704-981-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPORT-KW3AY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily