Provider Demographics
NPI:1588198063
Name:PORTER, JACOB RUSSELL (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RUSSELL
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:RUSSELL
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:333 N 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1215
Mailing Address - Country:US
Mailing Address - Phone:480-318-0354
Mailing Address - Fax:
Practice Address - Street 1:333 N 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-1215
Practice Address - Country:US
Practice Address - Phone:014-637-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00000000207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine