Provider Demographics
NPI:1518105543
Name:PORTER, JESSICA C (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:C
Last Name:PORTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:CONLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:735 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412
Practice Address - Country:US
Practice Address - Phone:207-947-0768
Practice Address - Fax:207-947-0699
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP091010363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9086OtherMEDICARE GROUP NUMBER
MEAP091010OtherLICENSE NUMBER MBON
TNAPN0000013628OtherAPRN LICENSE NUMBER
ME433873199Medicaid
MM9086Medicare PIN