Provider Demographics
NPI:1568440832
Name:PORTER, JERRY ALAN (CHIROPRACTOR)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:PORTER
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-2560
Mailing Address - Country:US
Mailing Address - Phone:509-535-1530
Mailing Address - Fax:509-533-5325
Practice Address - Street 1:3026 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-2560
Practice Address - Country:US
Practice Address - Phone:509-535-1530
Practice Address - Fax:509-533-5325
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT02517Medicare UPIN