Provider Demographics
NPI:1558062620
Name:PORTER, JACKLYN (RN)
Entity Type:Individual
Prefix:
First Name:JACKLYN
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 1:398 TOWNSHIP ROAD 391
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:OH
Mailing Address - Zip Code:44880-9764
Mailing Address - Country:US
Mailing Address - Phone:330-304-2049
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3891
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:440-204-4315
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH367979163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse