Provider Demographics
NPI:1568823060
Name:PORTER, JEFFERY
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 SANDY DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6050
Mailing Address - Country:US
Mailing Address - Phone:801-842-4987
Mailing Address - Fax:
Practice Address - Street 1:151 N 3RD AVE STE 404
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6331
Practice Address - Country:US
Practice Address - Phone:208-478-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34705101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health