Provider Demographics
NPI:1497450712
Name:PORTER, JACEY L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 SUGAR LOAF HILL RD
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-5435
Mailing Address - Country:US
Mailing Address - Phone:334-207-9160
Mailing Address - Fax:
Practice Address - Street 1:660 MCQUEEN SMITH RD N STE H
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7559
Practice Address - Country:US
Practice Address - Phone:334-350-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist