Provider Demographics
NPI:1508455858
Name:PORTER, JILLIAN (RN)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 BERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3424
Mailing Address - Country:US
Mailing Address - Phone:616-401-2343
Mailing Address - Fax:
Practice Address - Street 1:1264 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6816
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9525189163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty